0007-136 (SFD)•' LICENSED CONTRACTOR DECLARATION' ° >�� x�:« xg.
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I
her affirm under.penalty,of,perfury that I am licensed under.provlslons of 4-•
;; Chapter,9 (commencing with Sectionr7000)'of Division 3 of the'Business"and +'
Professionals Code, and mySLicense;is'infull force and effect t� � r 1 ••• � ,
License ff �: �?; ��`.��, it t v'.. Llc. Class iy t t s.;', Exp' Date
r"ri"Y �,r,1„a(,^.(,rrri), � ,,'.7 �#�� •�' � t/t�'•�7c• /:. F•a�•'rr'4. h j,r_�:�; �d'� J .•fvv.-.r.r..� '..'3'
r'••�'"k ir;1714)188 }Fti / �� �,:_ ,�i 2 +,r. •10/31/20
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Date ► r / ,r f Signature of Contractorl-
? atxrwLOWNER-BUILDER DECLARATION'',
I hereby affirm under, penalty of perjury that I am exempt from the Contractor's
License Law for the following reason
'as owner of the property, or my employees with wages as their sole
a compensation r will do the work; and the structure is not intended or offered for--'
4 sale (Sec' 7044; Business&'Professionals Code). ; ` 1 _s ' •'r-' _
e
(r,soterty
f;he,prop,,,am;exclusively contracting,wl
A);�,,as,owntti;licensed ,
contractors to construct the project (Sec. 7044; - Business & . Professionals
P' aTy-dj s r, ,: s -
ACode) �`�"'ti,•ti c:r%•r f!: •, r � � s ` � r � .
"( )wI am exempt under, Section B&PC. for this reason
uDaFat�etk p�' t� i+ ;r 'Signatureof•Owner e -
Ylt.v ,)i•f .k/v:�Y r:i. 7"IL'! ' l y.
WORKER'S COMPENSATION DECLARATION ' `
i+ .o'"mss/••: `�1C✓ n... .i� 1 /r ,:f.r. {`l "•,,+,i .> M"` " r -. -
" I hereby�afflrm.under penalty..of.perjury. one of the following declarations:
(,) I' I have and will maintain a certificate 'o f consent to self -insure for workers'
compensatlon�as` provided for; by Section "3700' of •the'. Libor Code, for the
7 performance of the work for which this permit is issued.
C (^) sl have and willt maintain workers' compensation insurance, asrequired_ by
VSectlon13700 of the Labor' Code 'for the performance of the work for which this
If—
Is Issued, my workers compensation insurance carrier &'policy no. • a'
i "e,1, GOLrk1.1 Al RA�i1�F IN
X-4
Policy No. Aft ",'(This section section need not be completed if the permit valuation is for $100.00 or less).
k(r) 'I'certify that in the pe' rformance.of the work for which this permit is issued,
I shaII'not employ any person in any manner so as to become subject to the
j workers',compensation'laws of California; and agree that if l should become
1^ subject to the workers compensation provisions'of Section 3700 of the Labor
! ode I shall forthwith comply with those provisions.
ate / Applicant —� r� ; •! ,,
.� 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 t6 the oost 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 andSafety
;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
`4 any permit issued as a result of this aliplicaton 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.
j�lgnature (Owner/Agent) 2r r '.�� Date 3 i
ti
-, o �,n,BUIL`DING' PERMIT°M;aP7wrT� rv7,i+ r:; Y2 inaV •�
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DATE ., F'Di)fl'-A� :�• � AST..r'"��' � �
DATE s Gc.. 5} ,,,+• VALUATION T y
���• ti:r •''Y �;
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i. i 7a � ,' ! 's:`, � :_•:rr ,;r�;"t• ' *:•,2..+ 7`'• ".`,:s..r.,: ,,..'f✓.:�r.., .I. ���..:.tt
JOB SITE lam-,. -a:ii r -. a .;;- a r .�•`�'ro +- ::,:t,-t�':.f t:
ADDRESS '"f'.pry�yy��yy•�yAgw >.. ., .;_ :'r; aA H.:, r -�''' ''7✓ •y. r
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J.F.Jei ,14Sr
OWNER T=
CZy C tOiFiET�: COIvQP+RG±p71Te'k b ~. '~
CONTRACTOR/ DESIGNER / EN INEER F4�. y ��t� rtuf
" CgW1'URY. CRO�t:L�.r1::i COA9Iv Lg4r JES
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153: So. V. 52 ann, ST(1. 0200 r;
<.15 �� �U;.°IJ°.S1R ul'� `'#200
SAN }3£ tl�l'AR�1�dO CA 92403 .r
k<aAN k3E2<'A1Ai3D1,AlC%,�::y'CA 924O> r f
- (909)381-6007
'Ya. Ya. ✓� _.. -+•'� <
USE OF PERMIT
"SWGIZ FAMILY Z>13t# ...._ „�
t:r. -» . �t� :�",.e.i�•.' r� a
aP+-'yD•�• LOT 11 PLAN ZRAa PERMIT DOM NOT INCLUDE BLOCK W �II� 6-R', :�;�`w�l+(�r �� •',
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i RACi Gt)A1; TKOCTION V1
36.00r0� S
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RPOR
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W'AnAGLU r/' l (i71) 0,232.00 , ,, ✓' f w �; i y''j�
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CONSTRUCTION FEE 101 «000--418'-600 --45'99,0
`~ 5'99 !®i�1�
PLAN CiiECK PEP 101-000-439-318"
MECHANICAL FEE 101.000-421.000
ELECTRICAL FETA 101-000420-000$109.40 �
- E
4i.v
PUUMBING FEE 101.000-419.000 "1122.75 •:'
T T l p r
S': RO140 MOTION FEE. RMID 101-000-241-000 ��p
/,`
tfMDING FEE 101'-000.423-oi101
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DiPVUDPER IMPACT FEE
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SUB-WTAL COAlS°!`Ftt7C`1. OR AND PLAN CBECZ .•; *-
,• « , X3,31 ��4
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LF9 P `RF. -PA F�1iM
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TOTAL Ph'1RW'1' MIS WTE S40W
is 44
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RECEIPT DATE B %( DATEFINALED' INSPECTOR
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS .
Set Backs
Underground Ducts
Forms & Footings
121
Ducts
Slab Grade
Steel,ZA
CA
(,e'er
Return Air
Combustion Air
Roof Deck
dp 'Z
Exhaust Fans
O.K to Wrap
o
F.A.U.
Framing
Insulation
(o�ao C,
11 �Z, ,pp ��
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
1 Qo V*dp>—
Final
_
Final 5
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
Waste Lines
Gas Test
Electric Final
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_
f�2p 62
Pool Cover
Sewer Connection
C� 12p e��
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 PowerZPj C�l
Final
Utility Notice (Perm) 2�?�
COMMENTS:
a
0:1/22/01 09:06 FAX 760 346 7276 PARAGON INSUL. 124
' I
INSULATION CERT FIC ATE �. � t IC -1
19.319 PASEO:DEL REY. LA,06INTA
Number acid Straet ; City
Riverside 27519
coon Tract No.
Description 6flhstallatioln;.
1 ROOF
Material.
Thickness (inches)
2 CEILING
Batt or ®IanketType°,':BATT
Thickness'(incnes) 12
coese' FiII T t : BLOWN IN.
Cohmacto s min-,insWiledoweigh►-oguare. 0 61541Ib-
M2nufacturers installed Wbightlperrsquare foot 1o•achiev6 hermal
3 EXTERIOR WALL
Fra®T1It7es
A Cavity lnsulation
Material
Thickness -(inches),
B..ExterTor Dain e$ ng
Material r
Thickness (incjes).,
4 FLOOR OVER GARAGE'A52E
Material
Thickriess'(inchs). ,
5 SLAB FLOC RIPERIMETER
. Material
:Thlckr>e,4s�(inct5eb)� '
6 FOUNQATI6N'14LL
Mat"i
Thickness (inches)
Declaration
I hereby certity.•thatthe above in'sulation•ww- installed in the building acid the above location`in
En®rgytoncy,Standis d*.,for residential buildings (Mede 24 �- ah 6 Caldrorn2- Lode cf Regu
Gertlficate'of Gomplianc�, wrhe�e.appiacabae:
2 11.19/09 PA}G
Item #Signature, atia ` ` Instellini
General
conformahee with the current
lations)';W indicated an the
Name) OR'Owner
Item #s SignahfrB, Date Installing, Subcontractor (Co. Name) OR
General Coht ai;i (Co Name) OR Owner
Item #s Signature, Date: Installing 5ubcon ctor (Co. Name) OR
General Contract (Co. Name) OR Owner