0002-342 (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
7144, 1 11,31 mut
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 OwnBr
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
perforrpance of the work for which this permit is issued.
(a) I/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.
t_i01 � �M4 L., Ng 9llT INS FJl
NV' F1 06'k.'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 3700 of the Labor
Code, I shall forthwith comply with those provisions., , ti
Date: =Ai,11.4-1 Applicant
.•° r.t!°A>t
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 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 for inspection purposes.
Signature (Owner/Agent) t . l�efl-� / t �•�S Date
A BUILDING PERMIT PERMIT#
/// 131012.442
DATE. �/- VALUATION LOT 10 TRACT
JOB SITE
ADDRESS ;?GiiA',i,5"us'*�vfis-�{k.F�� APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
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SAN 111--(tAi.M41)1xdO ("A 9240
USE OF PERMIT
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LESS
RECEIPT I DATE
iiO`t'AII, lal+:tttAlff 1 IIJI{S Ofif, NOW I so,261.; z
DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
- -L—W - ap }:t
Ducts
Slab Grade
6-1 -thy
Return Air
Steel
. Z-1- Qd
Combustion Air
Roof Deck
(a -?-(o. &6
Exhaust Fans
O.K to Wrap
1-.05 _ co
F.A.U.
Framing
`y
Compressor
Insulation
Fireplace P.L.
O ��QZ
t
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
q 006, ('y�Aai
Drywall - Int. Lath
Final
Final ��.Qo
BLOCKWALL 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 Lines
-v; -Clio
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
8 3
Encapsulation
Gas Piping
Gas Test
L�30
Appliances
Final
Final 1 m �-
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 Cao
Utility Notice (Perm)
COMMENTS:
*WESTERN INSULA TION � SNC. � {
4211 Latham Street, Riverside, California 92501 _ '
+ Tel. (909) 686-8760- Fax (909) 686-8786. .
INSULATION CERTIFICATE
THIS IS T0, CERTIFY THAT INSULATION HAS'BEEN INSTALLED INYCONFORMANCE WITH
THE CURRENT ENERGY REGULATION, CALIFORNIA ADMINISTRATIVE CODE, TITLE 24,
STATE.OF CALIFORNIA,, IN THE BUILDING LOCATED AT:
TRACT / PHASE: MARBELLA II - 23995-8; ,
-LOT # 10
SITE ADDRESS: 78-825 WAKEFIELD CIRCLE, LA QUINTA, CA <
.----------------.----.------------------------,---------;------------
EXTERIOR WALLS:
MANUFACTURER: JOHNS MANVILLE THICKNESS: 3 5/8 " R-\:ALUE:• R-13
CEILINGS: BATT' BLOW
MANUFACTURER: GREENSTO , 'THICKNESS: 10.3" R -VALUE: R-38
CEILINGS: BAT:TS BLOW
MANUFACTURER: JOHNS MANVILLE THICKNESS- 13" R:'JALUE:! R-38
=�---------------------------=--------------------------
GENERAL CONTRACTOR: CENTURY HOMES : -
LICENSE NUMBER:.
TITLE:
DATE:.Y�
+ INSULATION. CONTRACTOR: WESTERN INSULATION, INC.
LICENSE NUMBER: '481278
< BY:
TITLE: PRODUCTION MANAGE
DATE NOVEMBER 6, 2000 `