0007-139 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I arrl 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
/ 7)41X513 B �n ,,7 e„ 10/3112(
`f 1
Date-/ �YIt�F�.Signature of Contractor f r l �� ''• j-'`
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 0OLDXt4 i A01.L ISQS Policy No. N 6hfC-540068-02
(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
Cyode, I shall forthwith comply with those provisions"' %
Date: % h� 4, �. Applicant -%P). P)
� — f L.•4
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) Date
,.
u BUILDING PERMIT PERMIT
DATE -"' - VALUATION LOT OW7439 TRACT
$117,8415,x.0 20 27519
JOB SITE
APN
ADDRESS .79-269 P"!.�O 2, Fd>: Y
am -M-009
OWNER
CONTRACTOR / DESIGNER / EN (NEER
INTI RY C.,R.OWM L COSlAMUNITITS
C'.L'"1•M(.)RY CROWEf t . COli/11v1[EM-1 [Fs
1535150, "Do «8'MNE-1, ST.E. 0200
1535 S7. °Ia° mum; VM #200
SAN BMUJA12MTO CA 92408
SAW BERN'ARDINO CA 92408
(909)361.6001 CSU.1 2120
USE OF PERMIT
SI1 GU7 FA2,h1'l: Y DWELLING
SFD-LOT 20 PLAN 50RA PERMIT D02S IIOT )WCL.U11R T(L OCK 'MALLS OR
POOL.
TRACT CONSTRUCTION 21008,00 Sr
PORMPATIO 48.00 SFS
CIARAGR/CAR.PORT (SP) m73.2o
ES"MIATED COST Off" CONffiTRUC"nON
11.7,8415-00
CONSTRUCTION FEE 101-000-418-000 M2.50
P.L.A14 CHECK ME 101-000-439-318 Is- g I5
MECHANICAL I'EN 101-000-421-000 $53.50
ZL,FCTR1CAL PZZ 101-000-420-000
PLUM81INC1 IMRE 101-000-419.000 $146.75
STRONG MOTION FEE - RESID 101-000-241-000 $11.78
ORADIWO GEE 101.000423-000 $120,00
DEVELOPER IMPACT PEE $),901.00
SUFI-TO'T.AL. CO1r2WRLTMON• AND 111 AN C348C"K
$3,552.78
LESS PRE -PAIL' FUST
i$0.00
•` '�. s .AAAA '
1'i FMf .DUY YgOW
$3,5` 2.76
RECEIPT
DATEB
/, j
DATE FIN ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I W)01
Underground Ducts
Forms & Footings
_
Ducts
Slab Grade
Return Air
Steel�Sj
_
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
r �t—�
F.A.U.
Framing
do —`
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
_
1
Final
Final
_
POO SPAS
BLOCKWAL A PROVALS
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 Plaster
Sewer Lateral
47 CO C od
Pool Cover
Sewer Connection
_ {off
Encapsulation
Gas Piping
Gas Test
44 JAM_
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
Utility Notice (Perm)
�'"�
01122/01 09:08 FAX 760 346 7276 PARAGON INSUL. U06
INSULATION .CERTIFICATE
-79.2M:PASEd7dtL"kLY. LA I
Numibjr and Street
Riverside
.27519
County
Tract No
Description 0,16stalfiation
I ROOF
Material
Brand Narhe-,
Thickness (Inches)
2 CEILING
-Batt or BlanketType BATT
Brand Name
Thlckn 066ftes) 12
Thermal Resistance (R
Loosefill Type BLOWN IN
rand . CERTAINT1
Contractors min Installed Wtight square ft
square
-',0-;615 j6
4 Minimum thickness
-,
Manufacturer's installed weighteri'square foot to achieve Thermal Resistan:6e''(R-'V"aIuj)
3 EXTERIOR WALL
Frame Type
A. Cdvity Insulation
Material
Thickness (Inches)
Thermal', t6sistarice-(R
B. Exterior Foam Shewhing
Material
Brand Name
Thickness (inches)'.
T herrtW:Resistance:(R
4 FLOOR OVER GARAGE AREA
Material
.,Brarid'Nams
Thickness(inches)
-,-TherenalMistance7
SLAB FLOORWERIMETER
:Material :
Brand Name
ThIckness.(inches) Thermal*Rdsiftnce.i
6 FOUNDATION WALL
Material*
Brand Name,,:
Thickness Qnqhas)s- -Then?W-Resistance-i
Declaration
I hereby. certify that the above;insulation was' installed in the -building and thwabove locaftriin 0
Energy Wficleticy Standerds for'residerifiail-buii1dings (Title'24, part 6. Califronii Code of NiWai
Certificate of Comolian where appli6ble,
2' 111101PARAGO
Item #3 dsl9datune, oteTnF�_rin_g:
Kam #s Signature, Date
Item #S Signature, Date
IC -1
CRY
20'
. Ldt Number
ice with the current
indicated an the
Name) OR Owner
Installing SUbizn(rictor (Co. Name) OR
`,,General Coniiact06. Name) OR Owner
IrisWiling Suftion"ctDr (Co. Name) OR
General Contract (KCo. Name) OR Owner