0201-035 (SFD)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.
Licen_$e # Lic. Class Exp. -Date
Date^ -^�' Signature of Contractor *' a� ✓ j `K ---
i..
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 Policy No.
SITA,TR Aowl..) 1$83006-01
(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 subject1to the
workers' compensation laws of California, and agree that if I should become
subject to thie workers' compensation provisions of Section 3700,of the Labor
Code,,l shall forthwith comply with`ihose provisions/ r �'
Date•%„ bl,r f� ^ 2 Applicant f � 4
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 Lam( uinta, its officers, agents and employe s.
2. Any permit issued as a result of this application becomes null and voil i
work is not commenced within 180 days from date of issuance of s
permit, or cessation of work for 180 days will subject permit to cancellati
I certify that I have read this application and state that the above informatio
correct. I agree to comply with all City, and: State�aws relating to the build'
construction, and hereby authorize representatives of this City to Lenter'upthe above-mentioned property for inspection pu�poseV
Signature (Owner/Agent)' �'�1 aDate�
,�..� .�. ..
BUILDING PERMIT PERMIT//
DATE VALUATION LOTTRACT
JOB SITE
APN
ADDRESS
50-315 WA E'7E�;S'"lA IM SOL
772-050-007
OWNER
CONTRACTOR/DESIGNER/ENGINEER
RJ
Rax My , t.���yC..
''�(j�HJ�ctt�bo /�
X k BOX810
��°�-'' ym
14751 .Ml.GAS rbYDIU`t E,
x.ac xa a'rA CA,. 92253
1140 A? 85034
(6f17}x5'7->f, ClRlh 4990
USE OF PERMIT
M-NOLE 1'+AM)LY 1yW=KA3
SHG? . LCIT 66 PLAN' SP73AC3. PUMIT'DOES NOT INCLUf I BLOCK'
"'ALU% POOL, OR UNi1T+ MAY APPROACH
TRACT CONSTRUCTION 0.1900 Sy
PORCH/PATIO 1, 48,00 rr
t, 1A,RACSUtA';,fi►sR£'O r 763,00 up
:KS`1`".U.b'LI��.1' ) COW CFF C'f:)iW1".E1;1r14`•"n'O
=;410,60
i'llMiit IT FRE 9i�.t�MARY
CONS RLTt: ION M 101-000.418.000 s1,nuo
PGA. CH1~t. K FER 101-fiii�0,439-318, $1,100.17
MECHANICAL ME 101.000.421«ct00 st"O. 50
t.,;.IMTPtr AL FRE 01-000-420.000 ji?
P11t31t1±1BINO PFX 101.000.419.000 $31(00
vT110NO A9.MIO N "M o 11091D 101-000-241-000
O.RA?' THO H'1 F 1101 -C-00-423-000 x�tll,nb
i)E.'�k.i.4t)l JIIR JIMP.&C:"I' Frit �i1, Q'r.ZiD
AM 11N ,fjUBLIC PL,FnCES - I MMIC 70.000.445»000 $205.18
KM -fit: rAt,COXOMMIGIN{'ANDPLAN'CREX`I0.
LESS P-REWPAYD 141213
° IOTAS,1W&M F .M NOW
VStlex _0?
PMAY U 2 2002
MOF(pQUINTA
REC T,E—,
BY
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 6-6 - O C__
Underground Ducts
Forms & Footings
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
14
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath ✓�
Final f - / Z - Z�
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
Waste Lines 3� _
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral _
Pool Cover
Sewer Connection —
Encapsulation
Gas Piping
Gas Test s,
Appliances
Final
COMMENTS:
130 SIS C9
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 energy
regulation, California Administrative Code, Title 24, State of California, in the building located at:
50-315 VIA PUESTA DEL SOL, LOT 66, LA QUINTA, California
CEILINGS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-21
GEN CON C R: RJT ES LICENSE #�JoLeal
TITLE: 3 ULlJ'KLK57-t U 0�IU1
ON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
dTITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003