0007-150 (SFD)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.
License # - Lic. Class Exp. Date
7 �4• l fi� $ 10/31/2(
Date ����-'-p� � `! .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. 7b44, Business & Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner L
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 GOLDEN EAGLE IN1 Policy No. Ai'PiTC-544008-02
(This section need not be completed if the permit valuation is for $100.00 of 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
13/ode, I shall forthwith comply with those provisions.
VDate:..._•, ,t,/ // .s Applicant 't
` �s-1 :r .: � J
ot
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. ;
� % 7
PIgnature (Owner/Agent) r ,�:`'ti 1.I %�•f Date
BUILDING PERMIT PERMIT# ;
��`'~A�
DATE VALUATION LOT TRACT
IT1I7M6M 517 197519
JOB SITE
ADDRESS 79-290 S.,...,.,.MI . rrsa.6A Pa- �o De (R
APN
� 6041-061-
OWNER
CONTRACTOR/SIGNER/EN INEER
CF07J1<i Y CROWE11, CONfMU133PJ II S
CENMRY CRO LL COAat:iMT' MS
1535 SO, "D° ffRE E`l, UIM 9200
1535 $O, `D* .van= MM ##200
SAID BF RW.A TU)1NQ CA 92408
SANARDIa�U'O CA 92409.
(909)381.6007 CR141 2126
USE OF PERMIT
31114M.E EAIVMY DVrZ IMG
.%?D.- LOT 57 PLAN 508 PERMIT DOFF NOT INCLUDE 81.UCK VA! LS OR
POOL A% PLAN CHWC REDUCTION FOR MULTIPIX 18811K OE
TRACT-CONEURUC ION 2.008100 191
POi:CIVPATIO 48.00 SF
0ARAOEICARPORT 381`33.20
EW2. N.I& 'D COST Uir Cf9RYFRU(.°�'$ON
117 600
PST Ft SUNWARY
CONSTRUCTION FEE 101.000-4I8»000 M2150
PLAN CHECK FEE 101-000-439-319 $146.03
MECHANICAL ".9 101-000.421.000 $3159
ELWTRICAL IFEL 101-000-420-000
PLUMBINO FLEE 101.000-419.000 11146.7S
I1cTt N0 MOTION IEE -12I= 101-000-241-000 P).78
OR 4DIN0 FBI, 101.000.423-000 $20.00
DEVELOPER IMPACT FEE $1,907.00
ByYB'rA1. C0N'STRIiC`:TION AND PLAW CHECK
$3,114.68
LYM FIRE -PAM FEES
$0.00
brf'A• ".PMTMtn 6 DUE NOW
$3,114A58-
3:114,ERECEIPT
RECEIPT
DATE BY 4
'f,
DATE FINALED
INSPECTOR
lv-,✓
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
4=034Return
Air
Steel
Combustion Air
Roof Deck
_
o 2
Exhaust Fans
OX to Wrap
I a U
F.A.U.
Framing\c�t
_
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.Q.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
(t�
Drywall - Int. Lath
Final
Final
POOLS • SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
(_ �O _
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Laterales
Sewer Connection
{�
Pool Cover
Encapsulation
Gas Piping
Gas Test
1 t- —
Appliances ..
Final
COMMENTS:
Final
Utility Notice (Gas) I
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) 'Z�$
01/22/01 09:0.8 Fti 760-346 727..6; PARAGON`INSUL-.`. 20
' r
INSUTATIQN'.CERTIFICATEs; k: 1C-1
71m290 0ASEO: DEL'REY `. �.• S t lsA f��JINTA
Number ar d Strkt City -
Riverside 1 " 27518 57
Coun ''Tract No'. Lat W.mbe
Descripti®n of lnstillati®n
1 ROOF-
Material
OOFMaterial t3rari6NamB
Thickness-(inches) Tehyml--Resistance (R.Valued)
2 CEILING ;: —
r ..
Batt or'®Ianket,Typ® ,; BATT T.- Brand:Name CERTAINTEED
Thickness (Inches) 12: :_ �Themral-Resistan'ce;:(R-Valtt9).- R-38
Loose:FillkT' BLOWN-IN` - ,Bund "_GERTAfNTEED`
Contractor's min installed4eight-square ft r 0 615 lb Minimum hicGess _ 14 314 inches
Manufacture's installed weight persquare foot to'dchiev6 Thsrmal Resistance (R Value} I
E.. }
3 EXTERIOR WALL
FramikT Qge r
A. 'Cavi y.,insulation
Material:.: k•. Bn3rid Marne,
Thickness (inches) Ttiermal:Resistance (R-Valu)'.
0. Exterion.F_oam Sheathing _ +,
Ma4eriai ` Brand Name
i
Thickness-finches) x 4 Thermal ftsistance R-Val
4 FLOOR OVER GARAGE AREA
Material : Brand Name • .; .:
Thickness (inches}; Thermal,Resisiance WValda
5 SLAB.FLOOPJPERIMETER
Material ,,Branii'N@me
Thickness (inches) Thermal Resistance (R—Valu.)
6 FOUNDATION WALL
Materlal Brerid Name j
hickness` inches ., Thermal Resistance (R-Value)
.Declaration.
i'hereby certifythat.the above insulation.was installed in the building,and theabove location in confom�non with the current
Energy t: nicfeney'Standerds for residential buildings -(Tide 24 part S. Califronia Code of Regulations) a� indicated on the
Certificate of Complien where applicable.
2 t�i�' :9199/01 PARAGONINSIELATION
Item #9 na ure, Da "� F� `' ' Installing Sum 'ivactor (Co. Name) OR
General, Contra (Co. Name) OR Owner
Item ft Signature, Date ' Installing Subcol"ctor(Co. Name) OR
` General Contrac((Co. Name),OR Owner
i Item— Signature; Date Instslling,Subco tractor (Co. Na) OR
General''Contra6tme
:(Co. Name) OR Owner
i
- •�� tet. ; �