0201-037 (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 -Affect.
License # Lic. Class el /Exp. Date p 1
6V-16413 Z 111C "t,
Dater, tom, , � Signature of Contracto, to •-- ,..,, �. r.
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury,t6t' 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).n
( ) .1, as owner of the property, am exclusivelycontracting with licensed
contractors to construct the project (Sec. 7044; Business & Professionals
Code).
O I am exempt under Section �, B&P.C. forthis reason
Date Signature 'of Owner
I._
WORKER'S COMPENSATION DECLARATION
I hereby affirm .under penalty',of perjury one of the following declarations:
() :l 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
S ction 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.
STATfil FUND M239"_01
Mak '
(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„ma'nner so/as to. become subject to the
workers' compensation laws of California, and/agree/that if I should become
subject to tAe workers' compensatibn,proyislons of Section 3700/biihe Labor
Code, I shall forthwith comply w th"those provisions/
` / J
Date: N ? 141 .Applicants .% ,.,, J/k
Warning: Failure,to secure+Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,WO, in
addition to the cost of compensation, damages as provided for in Section 3.706
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;regLiest 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 isnot 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 author6e repl!esentatives o�this City to enter upon
the above-mentioned property'`for.inspection purposes. r
Si nature (Owner/A ent).�' ,”" f r z f(- Date d{c9 le"�
-SUILDING-PERMIT - PERMIT# .'
_v
DATE VALUATION LOT R� TRACT
DATE
��'.
JOB SITE'' .`
APN
.ADDRESS �✓
OWNER _
CONTRACTOR /DESIGNER /EENINEER
PJ vLrs Yv:0
1vYSInCrGrz,.v1C.
1425 R •4 NIV'EiViYY 7»tWY,
Lid ,QM1N'rA CA 92M
PRC M, A7, 185034
USE OF PERMIT
SIM > IXXf P3.007' DOM rafi s tYXIAIDE PI L>OCK
iAYAU�..a I?fJQY*Capt: ,C3iiW.KWAY.6bPPR.OACH .
Ckt mf o0w ro"€'R.11C'I'ION 44146,DP IV't.
PO R0 {flee int a,0+6 .s7ir lir"
` I Em".�-�tA:a.t'..r.D'4-o6Sn OF coal -fib `M11�..��or
MA'AM.'1t41'
CONSTRUCTION FU 101 w0e 18-000 $1121.7300
P1,A14 C°H!£iGN: CIr'
MECHANICAL ITT, 101 -OW -421-000 $143.00
\�
101-000-420-O $244-57
•�
PLUMBING FRUL 1 1 Otto -419.000 $282,00
snow Mo's low rer`r. s Faresm 101 Otr3=?�•1.;.Gil�3 ��.Gr.?f �.!
GRADMO FEE 10), -000-42-_.S-0.00 u
xn"V r -OPPR lAfll':i oT I?Y;1d x,a►0a.i3f?
ART ,IN PUBLIC. IS.WoU8-,- USK 270400445.000. _ $16.2110
".fko #L ;c4,�"I'' �dC1YlCal3 i^� 1 �i 3 E'`i A{:C"�',��
s L21.93 MmPAM FM
rom rr-rofff FEES D" now
MAY U,2 -2002
C®(Fl,AQUINTA
F1AIAtl9CEO
RECEIPT
BY
DATE FINALED VINSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
-7a Q 77 Elt G
Underground Ducts
Forms & Footings
i A
Ducts
Slab Grade
tl
Return Air
Steel
Combustion Air
Roof Deck—f�
Exhaust Fans
O.K. to Wrap
, Q2. _
F.A.U.
Framing
_ O.
Compressor
Insulation
6
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
G 2_
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
��
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
_
- Q
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVAL
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) �,
COMMENTS:
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;INSULATION CERTIFICATE ,
is to that insulation has been installed in conformance with�the current energy,>
�y
This certify
Administrative Code, Title 24, State of California, in the building located
regulation,. California
50-380 VIA SERENIDAD, LOT 64, LA QUINTA, Californias'
CEILINGS: •
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TYPE:'BATTS. MANUFACTURER: Certainteed . Thickness: R-38 .� r
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WALLS:
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TYPE: BATTS• MANUFACTURER: Certainteed Thickness: R-21 9 - .,
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GEN CO RA R: T OMES LICENSE #I /-
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TITLE:
PRODUCTS, A MASCO COMPANY LICENSE # 632072'f
.,
ON SCHMID BUILDING
'TITLE: '"
ADMINISTRATIVE ASSISTANT DATE ,11/13/2003 , _
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