0011-203 (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 # Lic. Class Exp. Date
71�i f3.. �v. 10/3l/2t
Date ' /!' �) 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.
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. t101. L)tt Policy No.
F�'9VC-�a44lkt58-tiE
(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 those provision5.1 ,^ 1
Date: Applicant—'
:?'ir'J . s•` Y t.J' �f` /' 1y
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1001000, 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. J
Signature (Owner/Agent) .' .7% 'J % :%J'%.7 .
Date
BUILDING PERMIT PERMIT#
DATE / VALUATION LOT �•`'TRACT
f! l�0 aJ J 27519
JOB SITE r
APN '
ADDRESS 79 -MO F.i SE0 DEL KEY
604-061-00
OWNER
CONTRACTOR / DESIGNER / ENGINEER
cw- rutty. ontowx'1 ,COMM114 ri.Es
C."J INTIJItyM, 0Wk11L..00M'CiI3Lr".
.1.535 80. WV Mary, MR 4200
1535 SO. Tv Mt M, 7t7a'. 0200
SAN T3MAR1971 O CA 92408
«iii EF"AhD010 CA 92A08
(309)381.6007 CBIX 2120
USE OF PERMIT
OLE l� lL;SC °tN s.T_1 C1
S?D o LAT fit Pl.t�Iii SORS PERMIT VOWS NUf WC".I;dFDL BLOCK
WA1 OOL - M3 PLANCHFICKIRE k:.F: DU t'i0N FOR MULTIPLE
ISSUANCE OF SAME I'IA14TYPE
TRACT COWS RUC'•T101d 403,00 SF
PORCHiw.t TIO 48.00 S
GARS+-MiCA.Rl ORT (LF) %ran
V7111myrD cour 01.1, CO1G93 R.4.+CA.dON
117,046.00.
X •i..icaivua� i75'�. biGa �CS.'J�.�i'
caos,ai3'�:lTmaPInR 101-000438-006 $702.36
PL" CHECK I XF1 0I1J�jC�1-429.318 $�1,,46.0�3]
gT�I01'
-421-000
,ELLCTWCA .. PE 1011--000420-000 $111.1 d
PLUMBTNG FEE' 101.000.419-000 914635
STRO100 MOTION TION FEE o 111I±SM 1 Cel-OM2,41-000 311.73
CRA.DWO PIE 101.000.423.00-0 .. $20.60
DZVEL(:3PiIR IMPACT nZ $I,FJtt"J.6Ea
Wk-TMAIL (SOATMUs:'1 ON AND PLAN C''R�B'..iC
$3,099.69
LM 1~T�M
$(0,9.y0�0
�-P,t�ID
�+�y y� pyo y� y� y��yl��pl;7�iPOW
TM
.G �l'r.1L6LAP .L' �ir�AeAT.�`.Y3 �7; �1'kS 6 DUE PO
/
gv"..'•"e'{i4% .
RECEIPTDATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
2A0
car -K
Underground Ducts
Forms & Footings
120
Ducts
Slab Grade
I -2-%Z8
Return Air
Steel
Zfi2@
'�Zp
Combustion Air
Roof Deck
Cn
Exhaust Fans
O.K. to Wrap
�Z
���'sZ
F.A.U.
Framing
3 2p
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
� (�n
y
q l F
_
Final
BLOCKW —1L/
L d PROVALS
Final
POOAS
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
Z IH
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans_
Sewer Lateral
Sewer Connection
1 t �j
1 r
CyQs9�—
O.K. for Finish Plaster
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
4
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICA 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)
05/25/2001 FRI 11:28 FAX
16011
INSULATII
iN CERTIFICATE
IC -1
•340 PASEO DEL REY
LA QUINTA
Number and Street
City
riverside
27519 62
. Coun
Tract No Lot Number
Descriptio
i of Installation
1 ROOF
Material
Brand Name
Thickness ii
;hes
Termal Resistance (R -Value)
2 CEILING
Batt or BlanM
i Type BATT
Brand Name CERTAINTEED
Thickness i�
o
ies 12
Thermal Resistance (R -Value) R-36
Loose Fill Ty
;: BLOWN IN
Brand CERTAINTEED
Contractors
in installed weight square ft 0,615.
14 314 inches
Manufacture
i Installed weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR)
ALL
Frame Type
A. Cavity In,
ation BATT
Material
Brarid'Name. CERTAINTEED
Thidknes:
nches) 31/2 -
Thermal Resistance (R -Value) R-13
B. Exterior F
ism Sheathing
Material
Brand Name
Thiclmesa
inches)
Thermal Resistance(R-Value)
4 FLOOR OVE
GARAGE AREA
Material
Brand Name
Thickness (ir
aes)
The Resistance (R -Value)
5 SLAB FLO01
DERIMETER
Material
Brand Name
Thickness (In
:yes _ �-
Thermal Resistance (R -Value) "
6 FOUNDATIO
WALL
Material
Brand Name
Thickness in
; es)
Thermal Resistance (R -Value)
Declaration
I hereby certify tl it the above insulation was installed In the building and the above location in conformance with the current.
Energy Eff/cienc .3tanderds for residential buildings (Title 24, part 6, Califronia Code of Regulations) as indicated on the
Certificate of Coi plianct, where applicable. �.
2,3A ------4/2-5/01 PARAGON INSULATION
item Fsignature, Da Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, Date
Installing; Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, Date Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
INS TI !N CERTIFICATE IC -1 _
1.360 PASEO DEL REY LA QUINTA
Number and Street City -
iverside 27519 64
, Coun .. Tract No Lot Number
bescriptic i of Installation
1 ROOF
Material Brand Name
Thickness!i ;hes Termai Reslstance'(R-Value)