0011-200 (SFD)LICENSED CONTRACTOR DECLARATION
I.hereby affirm under penalty of perjury that I am licensed under provisions of
r6hapter 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
71,41, B
Date f Signature of Contractor' L
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. '
(1,)' 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 Policy No.
- GOLDZN FAOLIS, INS, kat�lG-3�4Itl�-A1
(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: i .'G �'�'7fApplicant % //, /�`£'c.�_i:.,l.%�%.
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) ff ! Date
BUILDING PERMIT PERMIT#
DATEVALUATION LOT - TRACT
6 I{ g 1 pts ( i f� 1
27519
JOB SITE �
APN
ADDRESS 7We139 PA.KE0 Dl? L AtEY
604 ^Q.ZI-009
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C"F`t47'i,1RY E".ltt:3V&'L,1, C°%oMMI32JTLIFS
C J AJRY C120w;Ku. comm I.wna
1535 00, Ali" 8TF"n, ZJTE MOO
15.35 80, "D" 3'=q-, ,'7717 0.200
SAN Y3nNARDINO CA 92408
SAN Y3Et.86INWINO CA 92108
(909p81=ei007 CrUdi 2120
USE OF PERMIT
Sis'iy . LA DT 13 Pi..,P N 3RC PFRMIT ,D00NOT INC:dd3DS RI.d7CK
WAl.I. POOL -'75%PI ANCHECK FEE REDUCTION FOR'A+4LIE.,'I'IPLk
IMSUANCF OF SAME PIANJ i YPF
TRACT CO110TRUCTIOW 1.6".00 8F
PORLFi+°I)f TIO 94.60 EF
GA.RAGIUCAR.PORT (SP)
immimm. r'SisT of Gone tmB m!'.'N
10014W.10
FEFIar PER bXUKi4ftARY
CO WRUC3ION FEE 101.000.418.000 $643.09
PLAN CHECK FU 101-000.439-338 slas.515
Z+II:FCI`wI1CAL FFR 101.1000.421.000 $53.559
L.LICTIUCAL, YXX 101-000-420-000 �tOQ.69.
PLUMBIM01, FEF 1 Ol'-000.419.000 V29,75
STRDNdt71Y afION FRE? • MID 101-000-241-000 $10.05
GRADING NIX 101-000-423-000 MAIO
DEVELOPER IMPACT ]FEL-
e
IrOB-T(Y'rtlT. GONMIJ(;"'rlow AND PIA14 COMY.
$'2,,996.48
LESS PRE PAID_ S
W
TQ rAL.11KRM. T I►'KIES 12' C NOW
�l
$2,W6A6
RECEIPT
DATE i ,
BY (( f
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
-1- a
Return Air
Steel
p I _
Combustion Air
Roof Deck
Z��
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
3� co C _ILI
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
I&k—
Final
Final
_
POOLS - 9PAS
BLOCKWA
�4PROVALS
Steel
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
IZ1(lJ1
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral�1
_
j
Pool Cover
Sewer Connection
2�Lg
Encapsulation
Gas Piping
Gas Test
S� C Qfw
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
_,Z
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
Z
Final
Utility Notice (Perm)
05/25/2001 FRI 1.1:27 FAX
INSULATIO d CERTIFICATE
79 139 PASEO'DECREY
Wrnber,and Street -
F erside
Descriptiror of In
1 ROOF
Material
Thickness (inc !s).
2 CEILING
LA-WINTA
City
27519 _
Tract No
Brand Name
TermalResistance R -Value
IC -1
Batt.or Blanke .:"ype BATT
Bran&Name=- . CERTAINTEED
Thickness fine us} ;;12
TtierniatResistance: R=Value R-38
Loose FIII'Typ BLOWN'IN'
&666 - CERTAINTEED '
Contractor's`n ,.installed weight'square ft._ 0,615
143/4 inches
Manufacturer c- istalled weight per square foot to achieve Thermal
Resistance (R -Value) R38 '
3 EXTERIOR W I -L
Frame Type
X Cavity InsL ition BATT .
Material
'Brand Name-. CERTAINTEED
Thickness + ich�31/2
Thermal Resistance (R=Value) R-13
B. Exterior Fo ,n Sheathing
Material..
Brand: Name
Thickness i . aches)
Thermal=Resistance_ R -Value
4 FLOOR OVEF 1ARAGE AREA
Material -
Brand Name ..
Thickness (in
Thermal Res16tance_(R-ValUe)
5 SLAB FLOOR 'ERIMETER
Material Brand Name
Thfckness.(inc s) Them%I.ReSistance (R -Value)
6 FOUNDATION WALL
Material Brand Name '
Thickness (inThermal Resistance (R -Value)
Declaration
I hereby certifyth; the:'above insulation, was Installed In -the building: and the above, location, in conformance with the current
Energy_Effreieney. 4 nddids for residential =buildings (Tide 24, part 6; Cali rbria Code of Regulations) as indicated on the
Certificate of Con ian , where;applicable.
2,,3A - 412510.1 PARAGON INSULATION
Item #s ignature, D Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item *a Signature, Diate
Installing Subcontractor (Co. Name) OR
General Contracf (Co. Name) OR Owner
Item #s Signature, Date ' Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
[a 009