0108-015 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O c) License # Lic, Class Exp. Date
LLJ
~o Z r_ Date Signature of Contractor —
CD 0 `;
� U 0 OWNER -BUILDER DECLARATION
Hw I hereby affirm under penalty of perjury that I am exempt from the Contractor's
V) License Law for the following reason:
Z_ ( ) 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
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
p rr I hereby affirm under penalty of perjury one of the following declarations:
r H O () 1 have and will maintain a certificate of consent to self insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for whicKthis permit is issued.
CIDQ U ( ) 1 have and will maintain workers' compensation insurance, as required by
O � Q Section 3700 of the Labor Code, for the performance of the work for which this
0) 1— permit is issued. My workers' compensation insurance carrier & policy no. are:
-,t Z Carrier Policy No.
OD
Q (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: - 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 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.
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) i� _ Date
BUILDING PERMIT PERMT#
DATE VALUATION LOT _!%:.a_;1:; TRACT
i � r: i •i ':,. ,'� , 1 } 24197•2
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
USE OF PERMIT
3HOS FAMFLY DWMING
�?�'�,f •:. ;r}r;i)',f`.. • ;'tt 9ri;.
OF
z:'T ii. 49.00 .Silt
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AUG - 3 2001 �: :,_ 47.E
RECEIPT
DATE BY DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION I DATE INSPECTOR
BUILDING A ""^'GALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings a� 1 iv Ducts
Slab Grade B/3/��� Return Air
Steel ` / Combustion Air
Roof Deck ���/,5��j� Exhaust Fans
Q.K, to Wrap lei . JQ_ (yf F.A.U.
Framing Compressor -
Insulation �� �J r , fL` Vents
Fireplace P.L. Grills
Fireplace T.O. Fans & Cot it, ui� _
Party Wail Insulation ! Condensate Lines
Party Wall Firewall yj 1
Exterior Lath Q � _ h
Drywall - Int. Lathf/_ ,7,-rs
_ Final —
Final —r� -Z _ . POOLS -SPAS
BLOCI<WALL APPROVALb Steel
Set �.
Backs qs I
- - Electric Bond
Foot .
— -- !.
�_
Bond Beam 1 Approval to Cover f —
Equipment Location �^
Underground Electric
Underground Plbg. Test jT
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
1j111
ShowerPans
Sewer Lateral
Sewer Connection
T
Gas Piping
Gas Test
i _�-
h Appliances
Final
Utility Notice
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Piaster
Pool Cover
Final
COMMENTS: ,6/3
Final -
Utility Notice (Perm) t�
10;17/2013 01.00 FAR Z 007/019
INSULATIQN CERTIFICATE
f This is to oeriify that insulation has been installed in conformance with the current energy
regulation, C21ifornia Administrative Code, Title 24, State of Cakfornia. In the building located at:
r 79467 William Stone Way, Lot 11, Monticello -Heritage, La Quinta, Californit
r
CEILING:
TYPE: BLOW MANUFACTURER: Ceriainteed Thickness: R-38
W ALLS:
TYPE: BATTS MANUFACTURER: Cartainteed Thickness: R-13
GENE L 00 CTOR: CENTURY CROWELL COMMUNITfrES LICENSE # ,7/�//�
BY: TITLE:_ SC_j _0�
PARAGON SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
SY_ TITLE: ADMINISTRATIVE ASSISTANT DATE: 12I1212002