0106-403 (SFD)LICENSED CONTRACTOR DECLARATION
,,.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 :?Or Signature of Contractor
OWNER -BUILDER DECLARATION
I 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).
O I.am exempt under Section , B&P.C. for this reason
Date f Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under. penalty of perjury one of the following declarations:
() I have and will mintain 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.
(r.)~ 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
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
VATH FUND
(This section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the wo'rli 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 if I should become
subject to the workers' compensation provisions0�ection 3700 of the Labor
Code, I sh 11_fort with comply with those provisi6�ns. ►►'�"^
Date: 24.;r,4 .; Applicant—
Warning:`
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT. Application is hereby made to the Director of.Building and Safety
for a permit subject to the conditions , and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of thisapplicaton agrees to, & shall, indemnify
&hold harmless the City of.La Ouinta; its officers, a9ents and employees.
2. Any permit issued as a result of this application Becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes
Signature (Owner/Agent) Date `;;,/C Ie
PERM T#
BUILDING PERMIT
r
DATE / VALUATION LOT '0106403 TRACT
JOB SITE
APN
ADDRESS
'91-225 VIA I.Y.,1,100A � ..
;�724W:?-M .
OWNER
CONTRACTOR / DESIGNER / EN (NEER
RiT X?k,J L
T IA1# i°i3,4�.
L& QUIbrDA, CA 92253
0-1Ci. NIX ;AZ 8503
(602)257-1656 CMX 4990
-
USE OF PERMIT
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Y9t.1.`6 w(�iY.e,7:..I.dB.`it14PJ•1'tI ;.I `YS7 .�..�L.nYLV �.3•
SM - LM 9 PI AW SF2All? PKKElftIT DOES NOT INCf-.L1M, 51".1C
OMt 'b 0L 0.. i5silVEW,i`s.Y APPROACH
TIMM CONSTRUCTION 4,364.00
PORCHIPATIO 9a1,03.;p
724.0 SF
VOMMATM) 0.:'OU OF COfiMUC7110H
cttiNS`I'Rum)()'ty' YEz 101 w000-4-NT10,00 51,21:,59
'k
I$k.AN CliFfi.Y PEs: 101--000-439-318 $1,034.83
MOCHk>Qit ICA1.} 1f'Is'11, 3 �31.00i9� • I irJ. $#s4,[ti#
S)At1`,d'viCAllFEZ 101 -000 -420 -WO $44.9. --rA
I'3.i1A BIN41'1FEE I.ol-rJ0 -41q•wO 1277.0
S9`1t,1ONG MOTION 111at, - RY.: M 101 X000-241-000 06.31
OKI' WING r?R, $20100.
I]hy P7.t{4CY i��`9 $3,S6+iY.Cl.09
pa��.pT.Gt�'M..-op""EIR
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SAA .kA S"rJROC .0 WE'9C K.4' k 6`AcSM 01 ^N� 0-2.55-0F� 0 $L SI
'CA, 1:b '
' cot: ?�'` AND PW i'" ITEC
".190 s _
$5,038.21
C;, PRO 71,09
JUL 20 IT( Mw
$0.00
n
:E FINANCE GEr'T I
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
f•. 7 •, } t,•.
k
rl
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING 'APPROVALS
MECHANICAL APPROV LS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck9�G�(��
Exhaust Fans
O.K. to Wrap �Q G 0
F.A.U. _
Framing �
Compressor
Insulation 77
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 11 1
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
u Sewer Lateral _ _ _
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances r
Final
COMMENTS:
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)
INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current Bnergy
regulation, California Administrative Code, Title 24, State of California, in the building located at:
50-225 VIA DE MODA ,LOT 9,1LA QUINTA,CALIFORI%IA
CEILINGS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: F.38
WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-21
4ENCO6N OR: HOMES LICENSE#(0_j
TITLE:
SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # E32072
T TLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003
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