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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•Busines's and
Professionals Code, and my License is in full force and effect.
License # - Lic. Class Exp. Date
1OM1/2(
Dateignature 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& Prof essionals.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
p rformance 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 00LOPIN P.AOLF INS, Policy No. . )TWC-544063.412
(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' orthw'th comply with those.provisions:,`� �
Date: f� ! �)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) ` Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0011"x02 TRACT
67 2 519 '
JOB SITE
APN
ADDRESS 75. -= PAS190 DE14 M
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CENTURY CMIDIVELL COMMifW.f M
CEW1717RY MOWELL C OM:0A0NA.1U:,9
13 35 a0, vi 53rnm'a 4200
1535 30, V MfM. "T„ ITM, MO
SAN T'.MURDINO C.A. 92408
SM BERDe AR3NNO CA 924,08
(909)381.6ov. 01.133,10. 2120
USE OF PERMIT
SI -V • USC 61 P1,AR 3S PERMIT ISO.ES NOT IXCLUDF, 131,06K WALLJPOCIL •
- ?S'irro PLPeldCHECY FLEE REDUCTION FOR M(JUIPLY, 199UANCK OF SAM2,1
P1JkNT Y'PL
TRACT CONS TItUCTION 116119.00 f9y
P()RMPATIO 94.00 S?
OARAO ARPORT (Qu) R,I'wo
Ci,�ur or' COW MIL �t�'''a�f�lN
100,�460.1€B
xy �{�ry ,��,yp AE�vrWAIX`€�
F.PLi1'AV. U, li'�:. 11 i7 EPiV8LifABOmy .
MMU,
C ONS'I RUC 0114 FEZ 101 •fa(14D41 £3 G60 X643.00
PLAN CFIR+t:IC FXT_? 101-000.139-318 $133.35
MECII NIf;.c° L PP.E 101-000-421-000 $53,30
zLBc R.;r_A,L 18ati:E. 104 -010"20-000 $100.61
PLUMaTNO a 101:,000-419.000 9,12315
b'i
STRONG MOTION FEE • R T.L,SID 101--0013-241-000 $10.05
(IRADINO FU. $10.00
DFd'EI DPF,R IMPACT FEE $k,SC►P.OIz
SUB-'1'(Yi.! L C{3Y3STCd.'liMON AWL) PL,AX ivf' e
$2,996AIG
aii..OS PRE -PAID FEM
$0.00
RECEIPT
DATE, j _ °•- f
BY f''
DATE FINALED
INSPECTOR
INSPECTION RECORD
`i
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
12 Z$
Underground Ducts
Forms & Footings
nAvs e
Ducts
Slab Grade
2,A20
Return Air
Steel
(ZV$
Combustion Air
Roof Deck
Cgr:aL
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
3 1p
Compressor
Insulation
(2z ��—d�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
3p�
Drywall - Int. Lath
_
Final —�
BLOCKW LL APPROVALS
Final
Steel
�_ L
POOLS SPAS
Set Hacks
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
Sewer Connection
(2 1
Pool Cover
Encapsulation
Gas Piping
Gas Test
3 Q 14:
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:
05/25/2001 FRI 11:28 FAX
INSULATIC CERT IFICMA
A
79 -30 PASE0.0EL R
Numbor.'a
LA QUINTA
City
IC -1
R 'arside
County Tract NO Lot Number
Descriptior. of Install'ifloini
I ROOF
Material
-Thickness (in im)
2 CEILING
Brand Name.'.
'Termal-Resistance,(R-Valuq)
saft or Blanke.
Type BA -77
BrandNarne. CERT-AINTEED
Thicknes,61in
12 •
T.herrrihl!Rtiiistiihcg'(R'-VaIUO) R-38
LOOWRlf TYt>
BLOWN,IW
Brand - `-CEIRTAINTEED
Conitnktor's rr
1 in ' stalled weight, ' squareft 0f615WJ-.
X14 3/4 inches
Manufactureft
installed weight per sq'u'are foot to pchi6vle, Thermal Resiistanice,(R-Value) 1R3-8'
3 EXTERIOR W
11
Frame Type
A. Cavity Insu
Ion ''BATT
Material
Brand Name CERTAINTEED
Thickness f
2Les;)_ 31/2
Thdrmal,Resististance, (—R-Va)Ue),,. -R-13
B. lEktarlor Fo
'i Sheathing
Materl6l
Brand,NaM6-,
Thickness
.:hes)
Thermal Resistance (R -Value)
4 FLOOR OVER :.ARAGE-AREA
Material
Thickness (Inc :s)
5 SLAB FLOOR
Material
Thickness (in !s)
6 FOUNDATION'BALL
Material
Thickness (ind is
Brand,Name
Thermal Resistance (R -Value)
Brand Name:
Thermal'ReslsUhce-(R-Vaiuq)
Brand: Name
Th4rmalRet1stance (R;Value)
Declaration
lhereby ce"ft he at?OV@ insulation was installed in the build Ing, 6 rid,the 6 1 conformance with the current
-p1. v@ M tion in do " n
Energy Efficiency ;andeids,forrei�id,ential buildings (Title 24-, pan 6'Calftnid Cade 'of Regulations) as Indic . ated on the
Certificate of Com ano,,Wheke`,applicable. .
2.3A V �r(hb��4/25/01 PARAGON INSUL-AfION
Item is nature, Installing Subodritacto r (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, -Date.
Item Os Signature, Date
hL
Installing Subcontractor. (Co. Name) OR
General Contraa.(Co-'Name) OR Owner
Inst6IIi-ng-SubWntmctor (Co. Name) OR
General Contract (Co.,'Name) OR Owner
a 010