0011-201 (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 A Lic. Class Exp. Date
714188 1 10131/2r
Date h��'/."'' 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 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.
(;w) 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 COLDEN RACL,E WS. Policy No. 14we-544063-02
(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, I shall forthwith comply with thoseprovisions:-
Date: Applicant
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. /
Signature (Owner/Agent) 'I•�s p;cJ �f% Date r/ --"-S ��•'
F r r
BUILDING PERMIT PERMIT#
DATE j f VALUATION LOTOLD1.i.TRACT
E i .:.� l if •� F. yG,R '�.�fi 4 27519
JOB SITE ' ! /
APN
ADDRESS.. 79-32,9 PAff 0 DIL 14HY,
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CIEN'rU:idY C.aLOW L; , C0MMCf WOW
C.NIURY C"'RtJV11" -11 COMMUN:i"l� 13
1535.9a YU" STnpir',"i', s me #2aD
1535 k;O. U.Da W:i Wr, 17- x#',1.00
BAN BERN ' R40 CA 924N
SAN E',i?RNARDINO CA 92408 -
(949)381-6007 C°IsLO, 21,40
USE OF PERMIT
ffiNG E FAUMly JWMLbTG
;
SIFD - LOT 14 OJ AN 31 PERMIT I O&S NOT INCL UrDY. RIAXX
Wt1f..[.d'l 001, - 74% PLANCHECK ZEE REDUC130 FOR Wt;,' PLE
ISSUANCE OF SAME PL.ANT'YPE
TRACT CONS'1 RUCT1014 SF
a_,kP_ aEf ARPovrr (SLo 14,229.61)
EUM"TED C'057 OF CONSMUC.nON
PERWr FM SUAWARY
CONSTRUCTION FRE 101-000.418-000 $749.00
PLAN CHECK FEE 1011-000-439-318 $15%11
MECHANICAL, FEE 101.000-421-000 S0.00.
EI,FZTRICA.L PEP, Ed?1-QOf�-42Li• $I3Z,75
PL,1U/lBI'NO FEE '101.000419.000 Slab, a�
ST:RS7NO MOTION FEE " RMID 101-000-241.000 �43.0a
CI3$.A:O'i1$11l YKE 101-000,423.000 5.0.Q
OE/ELWER IMPACT FEE $I,9b'Y.00
�3UB-T7Y"AL CONS TLi.YD•r`f ON AND PLAN C;%•WA.X
$3,151.53
LESS PRE_PPM FFM
$0.00
I'OrTA . 7PEIMU C 7C.1 BB D'UE NOW
�3AX�1 »lii�
RECEIPT
DATE J
BY / �: ;~ /
DATE FINALED
INSPECTOR
_r
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set flacks
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 Wail 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
O.K for Finish Plaster
Sewer Lateral (2 ��
Pool Cover
Sewer Connection
I Z•
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:
•
INSULATION CERTIFIGATt"'z- ic
79-329 PASEO DEL REY
LA,dQ1`NTA
Number and Street city
Riverside
2751.9 14
County
Tract,No' Lot Number
Description ofinstallatio'n,
I ROOF
Material
Thickness; (inches)'.
2 CEILING
Batt or Blanket -Type BATT i.
Thickness (inches): 12�i
Loose Fill-TVDe BLOWWIN N�
Contractors'min installed wei§ht'sq'ua're ft,0;61;5`- -
Manufacturer's installed weight: per squarefojflo a[cWiev.e1T'"rm'i
3 EXTERIOR WALL
Frame TVDe
A. Cavity Insulation
Material BLOWN,IN
Thickness (inches) - i � "- , '3 1/2
B. Exterior Foam Sheathing
Material
Thickness (inches)' -
4 FLOOR OVER'GARAGE AREA
Material
Thickness (inches)
5 SLAB FLOOR/PERIMETER'
Material
Thickness (inches)
6 FOUNDATION WALL
Material
Thickness (inches)
Brand.N6m'e,
Termal R6si , sta nbe:(R7VaIu4).
iBrand.Name4,-'.'- CERTAINTEED
11R6§ist6hc6', -Valub),' "R38
Therma. �(R
Brand',: 'CERTAINTEED'y'
14 3/4 inches
Resistance.(R-Value) R-38
Brand,.Name�----. CERTAINTEED
Thermal Resistance -(R -Value), : R13
Brand.Name
13Brand.Name
Therffi6ILR6sist6nc6,'(R-VaIub)
Brand Name
ThdMialfesistance (R -Value)
Brand Name — ;
Thermal -Resistance (R -Value)
Brand Name'.'
Thermal 6sistafice (R -Value)
Declaration
I hereby certify that the above insulation was installed.in the building and the abov . 6 location.in conformance With the. current
Energy Efficiency Standerds for residential buildings (Title 24, part 6, Cblifrohia Code ofRegulations) as indicated on the
Certificate of Compliance• where applicable.
2, 3A V 7/12/01 PARAGON INSULATION
Item #s gignatur6, Djtb lnsti6lli6gaSubcontractor .(Co. Name) OR
Genera66ontract'(Co. Name) OR Owner
Item #s Signature, Date Installing Subdontract6r,,(Co. Name) OR
General Contract,'(Co. Name) OR Owner
Item #s Signature, Date lnstallingr,Sul6dont�actor (Co. Name) OR
General 0ntract(Po. Name) OR Owner