0109-021 (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.
License # Lic. Class Exp. Date
9064 E EtKC A ) A �(W,3 CM 2
Dated 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).
( ) 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.
HATE FUND 1521+136-00
(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 provisions.
Date: It Applicant ., % LLA, `} /J .f
Warning: Failure to secure Workers' Com pen sationjcoverage 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, 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 for inspection purposes.
0
Signature (Owner/Agent) l!t {1., Date:
w,J w
BUILDING PERMIT PERMIT# vor
fJ
DATE ! I VALUATION LOT 0109-0211 TRACT
$267A4140 70 29858.1
JOB SITE <
APN
ADDRESS �10� D���y 1 �±- - ,t y�,S�p� S
.1e�eIIt3� VIA l�il.C,a�Jl',CG h/.�.av `�90fY.s
OWNER
CONTRACTOR/DESIGNER/EN (NEER
;P�'l" TX1T,11C:
t�J"I'1"V`x, ic.
PO B0X. G10
1425 _' UOMW rrY URN
LAQVIMU CA 92253
PHORNM AZ 85034
(602)25'7•,16,56 (qP,'' 49911
USE OF PERMIT
SVTJ .LOT 70 J'1. AW V 4Ai,.:1. iF°Ei1f* I T' .L10 S N- OT INCLUDE BLOCK
WALLj% !'0011MA, OR DMV. AY A'MCN.A.C:i .
TRACT CONSMUCTION 4N&00 OF
PfIT'iCfT P r IO , 1,74ft>00 SF
OARAOFICaAWPORT '763.80131
XVITAIATKU C09i: OF C ONST7 UTM10.N
267„541.00
PE1Wr1' FFX' SrOMMARV
CONSTRUCTION FRY, 101-000-418-000' 51,2n so
Pf ,:N C:HWX VC -P, 101-000-439-318 $1,044.50
EC"HAINICAJ, ME 101.0004.421.000 $143.04
FLEC rttif":At., ?Z8 101 -OW -420-000 $242.37
F'LiJA1.4MMO Fibis 101.000.419-CK30 S182V
i'I'18.L1M MOVOW ?ZF,, WID 101 -N)0- 41-000 $26.75
tlF iI7J1IL1 �19,I� 101-000423-M) $20,00
DZY EL 'tPM IMPACT F ' , s f it r.00
.le,i T :1111 MOW PLACE'S . R ME 270.000-"5-000 S169.8i
, fir•
%:11IT3-'I"O�a'\L(';C:1�iS`%tt:l 1.710HA14D�'il.AN CI-MCK
$5,061.98
ISM) PRE -PAW FM
MOO
FSE0 6 2001 ,
CITY OF LA QUINTA
RECEIFt
q , ,�
Y
DATE FINALED
13-5—:S
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-%�L
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Roof Deck
_
/ -1 - [q 2. ���
Combustion Air
Exhaust -Fans
O.K. to Wrap-
Q2
—
F.A.U.
Framing
- L _Compressor
Insulation U
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
Drywall - Int. Lath
2=_ /�— �2
Final �_�
Final
� •- �j 3
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 Top Out
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
'�L �/�
Pool Cover
Sewer Connection
��
Encapsulation
Gas Piping
_
Gas Test
Appliances
Cf%
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
- ?j
Utility Notice (Perm)
Q
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:
50-360 VIA PUESTA DEL SOL, LOT 70,LA QUINTA, CALIFORNIA
CEILINGS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-38
WALLS:
TYPE: BATTS MANUFACTURER: CERTAINTEED THICKNESS: R-21
GEN CONT OR: RJrES LICENSE #
TITLE�GI'���(
SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003