0008-191 (SFD)LICENSED CONTRACTOR DECLARATION
1;hereb,`wiffirm under penalty of perjury that I am licensed under provisions of
'66apter 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
1(41 S3:
t1
D to %> w r s Yy Signature of Contractor
OWNER -BUILDER DECLARATION
1 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 6& P. C. for this reason
Date Signature of Owner
`'WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one ofAthe following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
comperfation;ias provided for by Section 3700 of the Labor Code, for the
performance of the work.for which this permit is issued.
�6X I have and will maintain workers' compensation insurance, as required by
Section 37`00 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 EAME1148. Policy No. NYI►C-544062-02
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 1 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•fb the workers' compensation provisions of?Section 3700 of the Labor
Code I,s� all fogth it comply with ore p ovlsiorid/ r
(f ate: 15 - j ((,,''� Applicant ,f 'I - V,
Warning: Failure to secure Workers' Compensation verage 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 i sp ction pur oses.
ignature (Owner/Agent) Date , {
U
• PERMIT # - -
BUILDING PERMIT1849,
DATE /�•' 1' VALUATION LOT. TRACT •.
I G' -00 27519
JOB SITE
APN
ADDRESS 79,300 P.iLWO DF1, R.".
604-061-W9
6 r061 -
OWNER
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CEI IRY CROWK lL COMMUNTTM
Ci'iJ WRY CROt)V.ML (MMMUNL'IYP'S
1535 30. `D` MLM. ST.E. 0200
1535 SCJ. "D" tTnu=, =, moa
SA14 B)"ATE.DINO CA 92408
SAN BERNARDINO CA 924LOS
(909)381-6007 CISLO x120
'
USE OF PERMIT
p�,p
079M�..- FAA+ LY D IELUNG
.
SFD-L,OT 53 PLAN 5K - Pa"•.,RI" UIr DOM NOT INCLUDE 131..0CK VI.A.LL OR
POOL.. IM44 PLAN CHECK FGM RErDTJC:TION FOR MULTIPLE 13SUANCE OF
SAME PL.PW TYPE
TRACT CONSTRUCTION $139.00 STS
QARA QW...P.RPORT (SP) 14,229.60
X9nN1.Af9D COS' OF CO1V'SML7t; ITON
PT:R T FTE SUADAARY
C WSTRUCTlON FEE 101-000.418-000 MOM
PLAN CHECK FEL l bl-a`1GU-4:i9-31 £S $ i 39.44
-MECHANICALFEF 101-000421-000 M.00
fri..ECTRICAL, FEE 101-000-420-000 $12175
PLt11J1BINO AEE 101-000-419.000 $131.23
47RONQ MOTION FRE - RE -SID 101-000.241-000 $1302.
OREADINO FEE 101-000-423.000 SLOG.
DEVELOPER IMPACT SIX- $1,907.Of>:
; ..
f ? rrl t_J
ERJB=PCTAL C:023'�1'12Li'C°I`1�ON AM PIAN CMM
!0.74.484
LESS PRR-PAM -
t:sK'0.00
TOTAL PrqM- T FEES VUE NOW
A 74M
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
.� BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & 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
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
I
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
Sewer Connection
Gas Piping
4Z���r o� (j�r s�—
Pool Cover
Encapsulation
Gas Test
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)
01/22/0.1 09:08 FAX 760 346 7276
CERTIFICATE
I 6—WV. VPN�iF—%J�LJF-L.r%r— T
Number 'arid Street
PARAGON `NzE
ra
27519
Trart.No,:*-.
IC -1 -
[a21
Ppscriptlon.of J.hMillAtilo'n
I ROOF
Material
Brand Name A' I.
Thickness (Inches)
Teftnal Resistance (R-V6IU'dD
2 CEILING,
eetf or Blank6t TBATT
Brand Name, ,.—
,Thickna�t (inches) A2:, A�e
,.—CERTAINTEED
�Rdsistgnee..(R-M
R-38
' Loose fill�`T BLOWN JN
lWand - CERTAINTEED.1,,-
`'Conbmctpes',min installed-,Weig-ht —square ft '0:615.lb
"IVIRmum thlEW&68"` 4 -143/4
inches
ManHfar I's Insialladw'eight Oar squaref6—t teachi6` hemral ResiiiancalR46148);
3 E)GERIOR-VVALL
Frame Type
Insulation
, y"nsulation,
MaterialS.
ThIckndsa',(lnches) I~Thefthiil',Aesist6nce
(R-Valq�)
S. Exteno(Fc*m3he.zthing,.-,'
Material
BrandName 4,:
Thickness (inches)'
TherrnFrzesiRance (R-VaIL49)
4 FLOOR.OVER',GARA-GE AREA
:MateF61L
%,:Brand'.Nime..
h icknesk(inchos)
ResISt36Cj6(RVaIbb):'
5 SLAB F PERIMETER
-Material
Brand:Name.�
Thiftesslinchas)
-ThdrmaPRd§istance-.(R-ValuO)
6 FOuNDATION WALL.'.
Material
Brand'Name
,Thickness* (inches)
TherrhMAOM41arice-;(R-Valu
Declantion
I hereby certify that the above insulation k4a0pstalled in the building
the,6bove l6batibn in c6nform,
ince with the current
7 " � �.
Energy Efficiency Standards for res'id'eniW.bbildings Rile 24..pa a 6W ronja e�jf RGgulafions)a�
indicated on the
celotificate of Co I' h re, 6p, plicab-le.
mp Ian- , w e e pp'c;' . 0' e'
2 1119/01
PARAGON INSULATION
ig -
Item #8 ignaturb,qDfte
Initallir4Sulamoritr-actor
(Co. Name) OR
n. CQntracj
(Co. Name) OR gwne*r
Items Sibnature,-Date
Inst0IIin9_SUbcorftfvictor
(CoMamd) OR
G mtmcd
(Co. Name) OR Owner
Gei'hetal Co. Name) OR Owner
0