0312-161 (MISC)-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 Codd, and my License is i6lull force and effect./
License -# , .'- Lic. Cla s/ �' Exp. Date
�Da1 r ". �X i ignature of Contactor%r'
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).
( ) 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:
( ) 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
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier lLlItlt�'I;? ,#t:3flaht Policy No. WC20002903
(This. section need not be completed if the permit valuation is for $100.00 or less).
() I certify that in the performance of the work.for-which this -permit is issued,
I shall not employ any person in any-mannere so as to become subject to the
workers' compensation laws of`California, and agreethat if I,should become
subject to the workets' compensation pr6visions"of,$' ction 3700;,0 the Labor
Code, I shall forthwith comply with those provisions it
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 this applicaton agrees to, & shall, indemnify
& 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.authoiize,repre§entatives of this City to enter upon'
the above -mention fp�ope� fo�sp�5%j'urposes. �
Signature (Own"e'r/Ag ne t).* Date'®s
BUILDING PERMIT PERMIT#
DATE —VALUATION LOT Q�r��lf TRACT
COO 2V. 30096
JOB SITE
ADDRESS ill -91'9V PUKRTAAWL,
APN
%62-.240- 3
OWNER
CONTRACTOR / DESIGNER / EN INFER
?aaXWti'AAY.,ULPAMN RS,1AC
DAMSH1':ED
3? 0.0 OW''iJ!'!'IMB0O1;(ES FERRY
169 MKOPY RON), L"M 105
PORTLAND OR 97224.
ENCINMUS CA. 92024
(7511)634.2350 CRUJ 420
USE OF PERMIT
SFD - LOT 2'L PJALV 1AV_ StFPt'UA+3P.N't'AL TO PERMIT 410311.038,
REti'i.3=M DU% CORRECTRD ADCtRIVIS
EM'1 AAD COST OF CON .17rRITC110N
O,i f)
k1UPPLEMENTAZ!'ERMIT RY, 10) -OM -423.000 Wo
rDEC2003
CITY OF LA QUINTA
FINANCE DEPT.
SUB 40TALCC2t�.rRUC''.10-1 AN`DPi-AN(1113CCK
'$4,50
LFM PRE-11AID FE EJ
$0100
T0T11 f,1`KH1Y r VEK5 DM-, NOW
or
TE CEIPT
DATE.`
BY,
DATE FINALEO
INSPE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Becks
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
a
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
E�
Drywall - Int. Lath
too
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
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
Sewer Lateral
17
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures J O
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
11-v%,L.P% i 1w1v vcR i iris,H 1 G
This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Code, Title 24, State of California, in the building located at
80-919 VIA PUERTA AZUL LOT 22, PHASE 1, LA QUINTA CA
CEILINGS:
TYPE: BLOW MAUNFACTURER: Certainteed THICKNESS: R-38
WALLS:
TYPE: BATTS MAUNFACTURER: Certainteed THICKNESS: R-19
GENERAL CONTRACTOR: DAVIS-REED CONSTRUCTION LICENSE #
BY: TITLE:
PARAG N SCHMID BUILDING PRODUCTS A MASCO Company LICENSE #221517
BY: G✓ r�l�-tet TITLE: ACCOUNT REPRESENTIVE DATE: