0007-138 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
r,hapter 9 (commencing with Section 7000) of Division 3 of the Business and
A*Tofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
71.4188 B iW1/2(
J
f date 711,11 �. , � �; •Signature of Contractor ,�f') i A'4}
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 C}OL+I gN. EaGIsR tgS. Policy No. Wt'.444469-02
(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
ode, I shall forthwith comply with those provisions.
j Date: L. Applicant
Warning: Failure o 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
te above-mentioned property for inspection purposes.
gnature (Owner/Agent) ,,; _;— % - 1-" i" y Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
$114 0AM-l.0 19 :27519
JOB SITE
APN
ADDRESS 79-279 PASE0 DEL REY
604 -W61 -W9
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CEA!'rMY CROVVEI.I. CONQJLJN -I9T:S
CaENWR Y C ROME -L COMWUNUIES
1535 S0. "D' 3TPJ1"r; S'CE, #200
15135 30. "TY b1'1 + Er, M #200
SAN BERNARDINO CA 92408
SAID! BERNARD). 0 CA 92+408
(909)361.6007 C.",1IX 217.0
USE OF PERMIT
U14GLE FAR LY DWEI LWO
SFD, 1,01` 19 PLAN 3A PERMIT DOES NOT [NCLUDE BLOCK WA1 U OR `
POOL, 75% PIANCHECK REDUCTION FOR MULTIPLE I53LIANCE
TRACT CONSTRUCTION 1,679.00 V
PORCH/PATIO P1.00 SP
GARAGE/CARPORT (JY) 0,1°Is.Y11
i SM IAT.= COST Off' CONS'.4 RUCTION
3 ()t),4W.10
PY-RW ii'r' PER SU11rgNFARY
CONSTRUCTION FEE 101.000.416 -ONO $643,00
PLAN CFI1: X FI+;F, 101-000,439-318 $133.55
MECHANICAL t> >E 101-000.421.000 $33.50
XLWT 101-000-42.0-000
PLUMBDIG IEEE 101.000.419-000 $128.75
STROIND MOTION FEE a REMD 101-000-241-000 $10.05
111RADING FEE 101-000.423.000 $79,00
DEVEL CIPER IMPACT ME $1,907.00
SUBTOTAL LOAI31RUC..TION AND PI..AAT C:HEC X
'$3,011.46
I.E,SS PRE -PAID MN
• /y'.I..T..':.' ,`y. �/���^
PY116 ow. ow
$1 /x$0.00
RECEIPT
DATE B /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
'..BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
11?l{�.oc� ��11
Underground Ducts
Forms & Footings12
,,gyp
Ducts
Slab Grade
�2Y(� V ��
I 2 0l
Return Air
Steel
(�a _ _
Combustion Air
Roof Deck�3
��
Exhaust Fans
OX to WrapF.A.U.
Framing
Compressor
Insulation
e(_(Z�
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
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
EesTest
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
Pool Cover
Sewer Connection
12',���
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
T _G/76//
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)
01/22/01 09:`08 FtLY 760'346 7276 PARAGON IN'SLL. @J 45
ICN CFRTIF.IC Tf�
' 794794?A.SEO'DEL REY
LA (1t
Numtior and Street
,Brand Name
Riverside Ft
-27519
. County.%>
`T'ract`No:
• Description of lnataffiadoW
Brand, Name,."... a
1 ROOF
TtieRrial;-Resistance`(R-Value)
Material
Name.3
Thiass inches
Termal:Resistance�(RVaiu®)
Thickness (inches)_
;- .T fid6iial;Re6istance R=Value
2 CEILING =
Batt or.@IahRetType BATTBrarrd.Name-.
CERT
ThUmess gnches) -12 �1-
Thermal Rd9istance.'R-Valu(
' Loose FillType: BLOWN IN . x' Y
Brand y' CERTAINTEED
Conu�actoft min lnstalled'weignt s00are ft 0 615' Ib
Minimum thir iess' 1�
Manufacturer's installed Weigfitper squaie foot -to achieve The.. Resistance (R -Value'
3 EXTERIOR WALL
Frame Typ® .
Item #s Signature, Date
A. Cavity Insulation
Material:
,Brand$yame . ,.
Thickness Inches)-
` Th4rmahR®^,istance(R Valu(
.6. ExtertorFoam Sheathing
Matertal;
Brand;Name=
Thickness"(inches):
.-TMrmaf Ri sMstance JR -Valu(
r
JINTA
City
4 FLOOR.®VER GARAGE AREA
Material
,Brand Name
Thickness (Inches)
Thermal Resistance R -Value
5 SLAB FLOORMERIMETEii
Brand, Name,."... a
Thickness (inches).. '.
TtieRrial;-Resistance`(R-Value)
6 .FOUNDATION WALL
s
.
Mlater(al
Brand.Name,: I
Thickness (inches)_
;- .T fid6iial;Re6istance R=Value
®eclaraticin
I Hereby"e *.that the above insulation % as installed`in the,bu ldingkand
the above locationi in confo nc
" Enerpy_Efl9ctericy Standards for residual buildings (Title'-, part`6
Gallfronia''6ode of:Repulatnns) as If
Certificate of Comp tan ,'where applicable.".
.r
-. 2. 1lisroa
PARAGON.INSLIU
Reins ion ature. R ®°
Instaurng Sabt�ontrt
Gert�rar: Coritroct (C
Item #s Signature, Date
Installing Suticonra
General COnract'(C
item ft. Signature, Date
Irista)Iing.Sut�contjra
General corn
inches
lC-1
with the current
cated on the
Name) OR Outer
it (Co.- Name):OR
Name) OR r