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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License* Lic.. Class Exp: Date
Date Signature of Contractor- �,r -••
OWNER -BUILDER DECLARATION
hereby affirm under penalty of perjury that I am exempt.from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following, declarations:
O I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of -the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permft is issued. My workers' compensation insurance tamer.& policy no. are:
Carrier 't� .i'L° W -! D Policy No. '"i�#�ut,..:iW,,!
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that tlf-1. should become
subject to.the workers' compensation prp Mions of Sections 3700 of the Labor
Code;• sKall fdrhwith comply with thoseJptovisions. t
tz) Applicant
Wa ing: Failure to'secure Workers' Compensation coverage is unlawful.and
shall subject an employer to criminal penalties and civil fines up to $100,000i in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor'Code, interest and attorney's fees:
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose -behalf this application is made &. each person at
whose request and for whose benefit work is performed under or pursuant.to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2, Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit, to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the .building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property fofAnspection purposes.
Signature (Owner/Agent) j''% '"- `-rt- -- Date
l is-�
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BUILDING PERMIT PERM � HM,, -d25 -
DATE VALUATION LOT PAR 14 TRACT
JOB SITE :??..i'VIy C�'iYt�t%� i�`L!f �!
APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/EN (NEER
1..!•1oS3Tx,"P.4 ��'•.= f�r}i . i.I;iC,4-'& GEYMk.,Al.. COW4A1X.X0,1Yir,clU; r'.
(%A 9,76613 40A 92r',60�
21 CISV�' 1756
USE OF PERMIT
f;11;41UD f'i.AX"i5: WIL`e••LS OR 1''OOT.,., 'Wi VN F<pRiiq".,:llk; 'llt't :l:'l,
PL3.RC-111 iiz ATIO 1,07-..t'O ;4F
Side?: NKLEi?.
t:;•`O13 t^'stela VION r, F 103 -(,GG-41 6-000
P'LAW C44—.X Fb.'tr, PAID& 6
,kA 1,C i 1 C,AL FEE 1013- !00.421.000 s2a- KI
TLX v; YVCA.L NEE t t?1 13CI�h 4�C••t1G�^ $°t!'d.bri
VU111YMP1111,10i "_ 1tF1*f`[ltlr4$ ^U�'I $1iG7. t4
;34TRONCt)gC•9'RC 9 FEE = Aa.ili) .101-000-M I.000 $ram
rs,F W1.00
t`&T W `r`fS1Y1;TC i'LAC'.V-1Ri,"1.E 270-f-00-445••000
f
�Ul:"-:iY�Te?►i:, �.�f:+1�1'�`�:.�t'.1.t'1.�i��Z�;-?.�;i�> #�'Ia:�;1•� f:"f :'��'���:
;i,4' �a, 9:?rt..±�Ci
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RECEIPT
DATEBY
DATE FI LE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
142- .Z - 3
Ducts
Slab Grade
Return Air — —
Steel
- $
Combustion Air
Roof Deck
- �, -
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int.. Lath
Final
Final
BLOCIfWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Again Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
i'.:..
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
_ iY
Equipment Enclosure
Shower Pans
r
O.K. for Finish Plaster
Sewer Lateral
-
Pool Cover
Sewer Connection
Encapsulation
Gas. Piping
Gas Test
Appliances
Final
Final _
Utility Notice (Gas)`
ELECTRICAL APPROVALS
Temp. Power Pole..
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles -
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) -
COMMENTS:�.�r��L•-
,
01/26/2005 08:44 17603401819
PAM 19/27
INsuLAT_IQN ER CAE
This is to cofffy that MsuMm hu bw kmMftd in omftrml3nCO with the mmrd M
jibeStw of Catiffmim, in Me building at
r"uWOon, Ceftrnlo Adminiatm" Code.
LA ouiNTA VILLAGE LA QUINTA CA
CE
TYPE: BATTS. MAUNFACTURER: Cerb*fted THICKNESS. R-30
WALM
TTS mANUFACTURER. Owens Coming THICKNESS: R-13
TYPE: BA
GENERAL CONTRACTOR: LUCAS GMRALCORMCMG CORP LICENSE 17 7
By., 4�0TrCLE:
PARAGON SC4D BUILDI
PRODUCTS A MASCO Company LICENSE 9 221,511
M
�PTITLE-, ACCOUNT REPRESENTIVE 16 1/
BY.
This is to cwW
regulation, Callk
CEI
TYPE:BATTS
WALM
TYPE: BATTS
GENERAL COW
PARA
INSULATION CERTIFICATE
kmIation'has been installed In conformwme with the current
'Adwkftkove Code. Tide 24, State of Ca#IbmIa, In the bujW
THICKNESS: R40
KER: CeflaIMOMW ESS-. R613
GENERAL CONTRACTING ESS: R-13
0TITLE-. -%-ft
0 BUILDING PRODUCTS AMASCOCompmwLICENSE *221517
TITLE:- ACCOUNT REPRESENTIVE DATE:
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