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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.
Licens? # • ° Lic. Class Exp. Date
7 4139; 11 1 �, • 0194) I M
Date 1{xltd �i
�Signature
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 ������y ( �q q9�w� f/� p/q� ��p� p9 Policy No.
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Q.u�:,II' DIN Sl.4.()I IIN2�. ii p9 �:-W°94062."VBG
(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.
� 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 J
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) A Datey
BUILDING PERMIT PERMIT"
DATE VALUATION LOT 0102-057 TRACT
14,649M 21 1.21519
JOB SITE
APN
ADDRESS
4.",'15 f A Al N0 YLMVA
1 M41_4*1_009
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1535 .010. ' r"1M-Mer, b3ITI- #200
1535 _S0, "D" STIM rd, STE, #200
S1BERNAitMIM0 CA kl'2408
VAN BERN.A1+'DWO CA 924W
(909)38 i ,6007 C B1.4 2120
USE OF PERMIT
31! OF ClAR (JU SPACIt, TO t,1 D-410 AREA OURINO 124111pi"
1� •rrala:~'�'o.01~i �a41<t1<c�rt�.. a�,13L�r,1:11�1�rf P TO M -D PERM1 ' 0003 -log
BONITO Room , 4 34. t�D 81?
1
PLAN C;HWX MI=L 101-000a439-318 $46,30
C:;DMTR.VCT1CrN YEE 101 -ODD -1418-000 �'a7Z.0i1
1G{/j�1�1.0000- 2eU-000�7
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$121.31
UK= .111RE-11PAiD M X0
$0100
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RECEIPT
DATE '
,lilt":ILi
B,
Yrr+�
DATE FINALED
INSPECTOR
1►
INSPECTION RECORD
OPERATION
I. DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs �'!y �� 8� �F
Underground Ducts
Forms & Footings
Ducts
Slab grade
Return Air
_
Steel ���
Combustion Air
Roof Deck y I��
Exhaust Fans
O.K. to Wrap I,_ ��.-$�C
F.A.U.
Framing % _ _
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection '� fed �yp e���
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final �i �
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 I �j C'
I
C00,
Utility Notice (Perm)
'01/22/01 09:08 FAX 760 046 7276 PARAGON INSUL.
INSULATION CERTIFICATE
45-815 CAMINO VISTA
Number and Street
Riverside 27519
Description of Installation
1 ROOF
Material Brand I
ThicOms (inches) Termal
2 CEILING
Batt or Blanket Type BATT Brand Name
ThlcKness (Inches) 12 Thermal Resistar
Loose Fill T e BLOWN IN Brand CERT
ntractor`s min installed wegM square ft 0.615 Ib Minimum thitkne;
Manufacturer's installed weight per square foot to achieve Thenal Resistance (R -Value)
3 EXTERIOR WAIL
Frame To
A. Cavity Insulation
Material
Brand Name
Thickness (inches)
Thermal Res
Ia. Exterior Foam Sheathing
Material
Brand Name
Thickness (inches)
Thermal Res
4 FLOOR OVER GARAGE AREA
Material
Brand Name
ThICKneg (inches)
Thermal Res
5 SLAB FLOOR/PERIMETER
Material ^�
ThicKne'ss' ,Inches)
6 FOUNDATION WALL
Material
ThicKness Cinches)
NTA
City
IC -1
Declaration
I hereby certify that the above insulation was installed in the building and the above location In conformal ce with the current
Energy Eftlency Standerds for residential buildings (Title 24, pari 6, Cardronia Code of Regulations) a5) indicated on the
Certificate of Complian ,where applicable.
2 1/18/01 PARAGON INSULATION
(tem #5 ignature, to Installing Subcore rector (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, Date Installing Subcontractor (Co. Name) OR
General Contract i(Co. Name) OR Owner
Item #5 Signature, Date Installing Sub="cAor (Ui. Name) OR
General Contract i(Co. Name) OR Owner
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