0008-187 (SFD)LICENSED CONTRACTOR DECLARATION
j hereby affirm under penalty of perjury that I am licensed under provisions of
ChapIer.9 (commencingc;vith Section 7000) of Division 3 of the Business and
uofessionals Code, and my License is in full force and effect.
License # Lic-Class Exp. Date
,/7141€i8 B
9 to e -� 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 t is reason
Date r* %' l) Signature of Owner ..
WORKER'S COMPENSATION DECLARATION
1 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.
Y` �7 I have and will maintain workers' compensation insurance, as required by
Se tion 3700 of the Labor Code, for the performance of the work for which this
15ermit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier GOLDEN RAOLE INS. Policy No. XWC--✓44060-02
(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
Code; II stall fo with comply With thos ,rQ. Isi ms.
Dgte Applicant
Warning: Failure to secure Workers' Compensation coverag001,$100,000,
nlawful and
shall subject an employer to criminal penalties and civil fines 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•Ahis City to enter upon
the above-mentioned property for i s — ection pur%po0�e+s-. /
SigAature (Owner/Agent) `� /_1 ,C �. Date — J
V -
BUILDINGPERMIT PERMIT# ,
DATE ' VALUATION LOT-�; TRACT
/ (? () 9130116010 18 27519
JOB SITE
APN
ADDRESS 9-289 VPM0 DFL REY
604 -061 -OW -
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CENTURY CROS C01ATvIUAIIdM
CT.—WMRY CROVV'6'"LL CO2ufAgUNni -
1535 30. 'D' 9T1 U7, UM 0200
1535 SCS. 10° STREET, MT. X4200
SAN BE NARDINO CA 92408
SM 13IK:.0 ARDWO CA 92408
(8091381-6007 C'.i3LY 2120
USE OF PERMIT
GIF, TrAhMY DVflM WG
SFD.L.OT 18 PLAIN 5LBR - PERMIT DOES NOT INCLUDE BLOCK WALL OR'
POOL. "'75;b PLAN CHICK 1�dfl,1": REDUCi ION FOR MULI TIPL1: ISSUANCE OF
SAw PLAN TYPE
TRACT CONSTRUCTION :2,139.00 Sl'
0ARACIFICARPORT (510 14,329.60
ES'.;I'IMAT D C'.09r OF CONSIY2UCTION
130,166..10
.rPERA1i`I'r, subudARY
CONSTRUCTIO14 PER 101.000.418.000 048.09
PLAN CHWK FEE 101-000-439-:315 $IM.46
MECHANICAL FELK 101-000.421.000 $78.00
ELECTRICAL FU, 101-000-420-000
PLUMBING FEE 101.000.419.000
7
�
STRDNO MOTION F E • RESID 101-0013-2611-000 $13.03
;f
GFcA1'. THO FEE J01-000-42'3-000 324.00
L EVEI.OPER IMPACT FEE
a'a
BUR -TOTAL COMI T i 11C ITION AND PLAN CMCK
$3,174.48
LESS PRE -PAID 1SES
$0.00
TOTAL PMOT FL'ES DUE NOW
$3.174.46
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
W
-X
INSPECTION RECORD
` OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
F,)rms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
Sewer Lateral
a.0
O.K. for Finish Plaster
Pool Cover
Sewer Connection
1�h_
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
01/22/01 09:08 PAX 760 346 7276 %PAkAGON INSUL. 004
INSULATION CERTjF1CA%.'--'-,�.`: IC -1.
*489` pAst6btCky LX 06INTA
N u
inr-b*' d Sf. City
Riverside. • -27519
Oda, SAW
Co
Tract -Kio
County. Ct AmeWCumber
Descripfion.of Instaliddo'n
I ROOF
Material
9rand.N10me,
Thickness (inches)
TermalAe.§istance (R -Value)
2 CEILING
Batt,or Blanket 1yeg BATTn
_fh_ickhes,s
86 Name
CIA�` 9 .'C 4 ERTAJNTEIED
(inches) :A2
_.R-38'
Lobse Fill Tie SLOWNIN
®rand CERIAINTEED
.Contractors min installed Wdigot,§qyareft 0.15151b,
MiniryiUm i
K 14 /4 InOw
Manufacturers Insta 10 weight pefisquare foot to76chi0ve-Therfri'al Resida ik e
nce
3 EXT-06ORWALL
Fraffw6.Twe
A. Qjvfty I Wation
Material
Brand;Nam&.
Thii*ne&Alriches)
Thermal Resistance(R-Value)
B. Exteirloffdam-Shasthing
Material
Wan N ame
Thickness' (inches),
"Thsrrrial<Resis�nt:e {R -Value)
A"
4 FLOOR OVIERIGARAGE AREA
Material
Brand Name
Thickness inches) -
ThbIrMal'Resistarice`(R-Value)
5 SLABkFLIDORPERJMETER
Brand. Name" -
Thickin (inches)
6 FOUNDATION WALL
Brand Nam6:.
Thickness (fthei)-
Declaration
I h@reby qrtifiihat ihe above ihi§ulaton,'6s,instalIed in the bdildingtand
above,
the above-, 166ati"brijn:oonf6rm�nce with they current
_6oda,
Energy Efficiency $iabdaidi buildingsJitlee'.24".' , p'aq6,-
Califronia indicated on the
Certificate of Complian where!appililcable.
2. .6 1/1,910
`PARAGON' INSULATION
nem #S ioriattirei, Ebte
lnstallihd=SUbcMtrattor (Co. Name) OR
- 1Contract; General n'trad : (Co. Name) OR Owner
Gene
Item #S Signature, Date.
lnstalli4,Subcontractor(Co. Name) OR
-
';general- t6nfiact� (Co. Name) OR Omer
Item #s Signa.tu .. re, Date
Iriftallft Subt.-onhetor (Co. Name). OR
G. neral Co-ntra ct! (Co. Name) OR Owner