0109-022 (SFD)LICENSED CONTRACTC R 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
r r 69045 D X110 A
Date-, A ✓, Signature of Contractor 7
--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.
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:
Cartier Policy No.
(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: 19 s Applicant 4 t;. (! f
TWarning: Failure to secure Workers' Compensatiori' 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.
a
I certify that I have read this application and state tha6he 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 foginspection purposes.
)� s Q
+ J +
f Signature (Owner/Agent) a' ' c.' Y" Date n?)
BUILDING PERMIT PERMITN
DATE % VALUATION LOT 0't09-Qll_)2 TRACT
JOB SITE .---
APN
ADDRESS
410 VTA :'i7P.X°l, SOiL772-0-W-007
OWNER
CONTRACTOR /DESIGNER / EN INEER
R.Tr HOMES ILC
ELJT R4VE 'I3o/C -N1S, )HC.
K) D+ N., 810
1425 K 'fWA;EK,ti,15M D.IMB,
Lam. QI.I€NTA CA 92253
T410RUIX AZ
95034
(60) ?57.11656 MIA1
14990.
USE OF PERMIT
1�/'y�j' ��� T- A � CgT �y '1.'t��'1
'Y,.TS1d.� .L'J'SkWJ.L.A F, i.1 tlF.H1{�ki-4{iSSU
SFD -1,01'69 Pf N S1i2ACZ, PERMIT T_)DiZ NOT INC'I.UDY HLOCK
"�i`.E3.1.14 POOL7.l PA t)R;, DRIVEWAY
TMC'1' COA1:9`!`RUC 71011 4,3f41W 91
i?ORC;F IPJLTIG 901.00 SP
G+L>, AMWARPORT 724,00 SN
IM) 'A� �t F CX)S'�S..%1�.UCM'(5H
263,mm
�9�'y� y� yy �,'y�- y J, �.(Ea-i'sTIfll�Ad"
P 6 ''j!:` ]7 �.'1lD,t i7 S.�JftFb1 a': 7°
Pl. Kbi CHECK FFE 101.000-4.39-318 5259X
WIXHANICYAL F.E 101.000.42) -000 $1510.00
1%F,C 1UCA1. ) C+'1-�EL7G-k, C1-t� iii $.7M9. a
PLUMBING FEV 141-Q)00- 1;i) -(?W 132V.100
ZATROND MOTION FEE • 17.i ID 101.000-241-000
C3RATAN. 0 PEP 101-000-423-000 S".00
C LVELOP IR IMI9ACT PEE 3I,SfYr1.00
AE.? 114 PUDIdC MAC - RJE 1I: VO.000.445.000 $I;7.115
i
0tTk3-S(Yk I' .1 k2�3Q.=10. i.1aK),VLOT CJkWX.".'K
$4,260.59
1X323-I'IRR-PA.?D RM$0.00
rKA.I,. ' R !91.1 1.+' : xA NOWF26O
P[SEP
0
0 6 °2001
,1
CITY OF LA QUINTA '
FINANCE DEPT.
i
RECEIPT
DATE.
BYD
I L INSPECTO
-
Fi f
IL
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING-
APPROVALS
MECHANICAL APPROVALS
Set Backs
�_� �. (
Underground Ducts
Forms & Footings
_
C
Ducts i
Slab Grade
Return Air
Steel
Combustion Air
vi_
Roof Deck
-
Exhaust Fans
O.K. to Wrap
yj• p
F.A.U.
Framing
l ��� 0
Compressor
Insulation
—G_ �j
_
Vents
Fireplace P.L.
Grills /
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines Ell
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
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
�� 7--G' /�L�/
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
'n
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
r'/ /
Utility Notice (Gas)
_ _
'—
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
_
Main Service
Sub Panels
U-4-1
Exterior ReceptaclesG.F.I.
IF
Smoke Detectors
Temp. Use of Power
Final
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:
50-410 VIA PUESTA DEL SOL, LOT 69, LA QUINTA, California
CEILINGS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-21
LICENSE # LD
TITLE:SI.tDM&) 1W
TS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003