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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 ,
sm�a D We A,,�.cift�
Date 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 STa9,`f.•R FUN Policy No. 1153390 -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 subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3.7,.0.0,of the Labor
Code, I shOtfo ' with'comply with those provisions
Date: + _ Applicant
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 hi°s
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 t6
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinja, 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 i
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.
`,-Signature (Owner/Agent) Date
AUILDING PERMIT PERMI
DATE . VALUATION LOT 9 ' TRACT
JOB ADDRESS 50-QZ iii, WEREI'UD APN ?7 4i d1"aYa+ `s
OWNER CONTRACTOR/DESIGNER/EN (NEER
F0 BO'S4; S{ 0 1425 1& TIMVEWSPN �;tRIV
LA QUIRTA Cts; 92233 P'r1O:V:l+ M fig" 95034
(Go?.)25 r- a 656 CBW 491.70
USE OF PERMIT
SKID I- LOT 62 FL AH :lF1. CTI. PKk2KIT ODDS NOT.JNCI:I1DiF SI.t:CK
WALf'.,5s, j° OOJ.,, Olt DF{ 1';li'l;{v1T/s Y APP ROACH
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TRACI VONSTI3UCTION 11.41
i'C.II'iS::d•Ii"k?�'i'[O , li(t�.00 ��'
Ctt�3 C 61C ^s1:1�CtPi� IMOD 8F
CON 83'.l RUCT3014 FEE 301-000-41 8 -OW $ 4,14 , 50
PLAN C;tiWX PEE 101-000-43£t-318. $ .9,65
M1:C.MNICA1.. MME 101-000-421-000 $0100
r;LFIC7`.RIC,°15L,hU-It 101.0017-420-000
P�UId343t1�4<3'447..3: 1t;1•43(1L'1n�t�,:r��U ��ag,f:� ,
STROIJO MOTXON 1;V3 r t?,1?„yiD 11'11-0ilti-2.4`l-000 x°24.35
ORADING HER 101-000-123-000 $15,0
LM. �_1.Z1P�,.R I.MP 3.0 i' IFi ti? $?,405.00
ART M i'CfBi'AC PLAC YNS' - RMir 27.0.000.945.000 $108.05
SUB—'OTA' LC.x'VR`t:^ IRIj ..A . 1C+f ;�.Sv::�.�Y.L�iti.kV �NECK
LESS.1:R1s4PAID X=rl $0.00
1. LrVTyQUINTA
RECEIPT [DATEDFINALEDD Y INSPECTO /
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
—
Ducts
Slab Grade
Return Air
Steel
_ p L
Combustion Air
Roof Deck
2
Exhaust Fans
O.K. to Wrap
3 _ c _
F.A.U.
Framing
_ _
Compressor
Insulation
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
— --
100T
Final
2j —
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
Electric Final
:Waste Lines
Q
Heater Final
Water Piping
17 r
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
Gas Piping
GI -1 _ G �-( _�
Encapsulation
Gas Test
Appliances
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 - 2
Utility Notice (Perm) '3
0
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:
50-455 VIA_SERENIDAD, LOT 62, LA QUINTA,CALIFORNIA
CEILINGS:
TYPE:BAITS MANUFACTURER: CERTAINTEED THICKNESS: R-38
-WALLS: ,
TYPE: BAITS MANUFACTURER: CERTAINTEED THICKNESS: R-21
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4GENE T CT : RJT ES LICENSE # (O -
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TITLE:�C�U C��l�%UJJZ
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HMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003 e
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