0109-020 (SFD)LICENSED CONTRACTOR DECLARATION
I hercisy 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 !' :afi`.v�".r,t . • `?,.
tJ
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.
'TATE LUNO 1383906-00 ..,;
(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 if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisio Is..,
Date: �• l_ Applicant 01 ++ f�
Warning: Failure to secure Workers' Compensation Zverage 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 authorize representatives of this City to enter upon
the above-mentioned property fo inspection purposes.
Signature (Owner/Agent) ` ~�� 'tDate
.. BUILDING PERMIT PERMIT#
DATE �f VALUATION LOT 0109 -MO TRACT
JOB SITE' APN
ADDRESS
50.310 WA JIVEMATam., NOT,
OWNER CONTRACTOR / DESIGNER / EN &NEER
� a 13rr.4; 1 n X 1;�3 if l +`1 CY' YIK'I'i ;
i.. QUINT.. CA 92253 PHOENIX rpt.`, 93031
(602)257-1656 M U 1, 4990
USE OF PERMIT
SITZ? s LOT 71 P3AN SMC2.. PERMIT I OES x OT INCLUDE DE H t: CK
VI'1.ti" PIKta.:IAPA OIC .DRJIVKWAY AYPIWACH
TRACTCON13TRUCTION 41364100 91r
A(yC(1.d��)�;��lIlJ���Ry.�q`TpyO,, �y�y s9yi7)�.1.00 S}r
.00
�y y��pp*F q��,�;y ��yg,�^y��.�A �;�S/"A".��6+� I C01W, O �'-G�NSTAITtt.'" JON 20,x.:98'.0
dCS=2�Ci7rO 3�� kJ bSe,{.' • /7r W dYrA.iYiA R :L
CONIS 1'Ril'1">TION FEE 101-£. 00.41 8.ON) $1,21.130
1T'f1AN C 11MC : F7211 101-000-439-3118 $1,036.33
I+dMMICAL Y&H 101.000~421.000 S6:30400
Z�'.3XIC-111PIVIA4, MK 101 -OW -42.0-000 719.' 4
[aL[IMMING FRE 101-000-419-000 SZY7.00
;s'TR,0140 lIsi3`Z'I.ON FM RESID 101IWO-2.41-000 $26.31
ORADINO FII 10.1-000-425.000 S200
j:a.VIVO.R.C.1PU IMPACT YEZ $3,907.00
A1Q,'C'IN Ptl.BLAC PI A+,CMS - :RFXI:C Z70-000-44-'5-000 $157,83
St7B40TAT. CC)M'MUCEC?I<1' ARD PLAN CVX,, ,` X $5,038.21
1.EM k' =a AU) FEISS $0.00
D Q
SEP 0 6 2001
CITY OF LANCE RUIN A
RECE BY DATE FINALED INSPEgOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
_ _l
Underground Ducts
Forms & Footings
Slab Grade
_
G
Ducts
Return Air
_
Steel
Combustion Air
Roof Deck_
O.K. to Wrap
-Framing
Insulation
Fireplace P.L.
-�%p °� %�
2 9 - —
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
l2 C>Z
Final _ ina�
BL-OCKWALL APPROVALS steel .
POOLS - SPAS
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 Lines0-
Heater Final
Water Piping
Plumbing Top Out
Shower Pans
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Sewer Lateral_
Sewer Connection
/�, ���--•
`
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
��
Final
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:
50-310 VIA PUESTA DEL SOL, LOT 71, LA QUINTA, California
CEILINGS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-21
GENE ONT R: RJT OMES LICENSE #
: OC9J
B / TITLE,3QR&K[ VT�W , W
N SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003