0011-199 (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
E,sofessior,,Js Code, and my License is in full force and effect.
License,# Lic. Class Exp. Date
1St 111
Dated 'ems 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 " Policy No.
CIOI.T9XN E>EiCRLH IN0. NW -MOSS -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 those provisions -2r
Date: M'f'r, ` APPlicant -:r' '� a= :•i,.'w t./
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.
�i
Signature (Owner/Agent) r + Y;-2., -i a°J Date
BUILDING PERMIT PERMITk
DATE VALUATION LOT' ilO�•k•"1 TRACT
JOB SITE 0 APN
ADDRESS 79-M9 .PAnUSPO DEL MY 604-061.•009
OWNER
C ` -URY CROWD L COMMUNinES
1 535 30. k:O-4209
SAW NE. RN•A42.I7INO CA 92408
USE OF PERMIT
CONTRACTOR / DESIGNER / ENGINEER
CENTURY Cf3.OWI~"R..I.. CM0,01WIF.1I
1535 00, OD" SIMM, STE. #200
R3.R4i3' :13 Al DIWO CA 92 408
(90V)381a6007. . mix. 2120
e1YD a LZIT 121 AN 5LRA. P2,RWI'r DOM3 NOT INCLUDE 19id7CK
W'A:, UPOOL Z.5% PLANOW. K FEE fit°,0Wl` ON FOR kaf O tK&
ISSUANCE OF R"IE PLANTYPE
TRACT CONSTRUCTION TION $133XV STS'
C" AXA* E/C 4XPC` .T (.90) 14,839.60
ff UB -TOT L CONS7`,Ra.L3M1014 AMD P1.A14' C''L,1EXX
I.aus Ppm, -PAW PER -5
*TOTAL P.OMEIr YJRES DUKNOW
RECEIPT I DATE - I�Yr �' I DATE FINALED I INSPECTOR
S3;`1:S 1.63
$0.00
Pkmu.rrEu summAww,
CONSTRUCTION ME
1101 wOt 0-41 S -OW
MO,t1si
P1aM4 CHWI;1EE
101-000-439-318
$133.11
M'EC:R ANIC°.AL ,17 .9
101X000-421-000
105.09
BLEC f RIGAL M,
$112.75
PLUMBING FEE
101 -000-419-000
$122.73
STRONO MOTION M. IMSID
10i-00-241-000
$1.102
0RAD1140 FEF
101.0010.423-000 ''
$24.00
DEVELOPER MPAC=T ITE
$1,07.00
ff UB -TOT L CONS7`,Ra.L3M1014 AMD P1.A14' C''L,1EXX
I.aus Ppm, -PAW PER -5
*TOTAL P.OMEIr YJRES DUKNOW
RECEIPT I DATE - I�Yr �' I DATE FINALED I INSPECTOR
S3;`1:S 1.63
$0.00
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade i
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 Wall 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
i
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
12 tH CO
Heater Final
Water Piping i
Plumbing Final
.Plumbing Top Out
Equipment Enclosure
Shower Pans
1
O.K. for Finish Plaster
Sewer Lateral }
Pool Cover
Sewer ConnectionI
«S�'—
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
i
Final
Utility Notice (Perm)
COMMENTS:
INSULATION .QERTIFICATE
79-349 PASEO DEL REY
3
r LA QUINTA
1
Nuriiber and Street'
°' ; City
Riverside
275.19; 12
County "'
TradNo' - Lot Number
Description of Installation ``
f
r
;
.
1 ROOF
Material ,
Beand+Name �," ,.;
Thickness (inches)
Termal..Resistance.(R-Value)
2 CEILING
Batt or Blanket Type BATT
Brand'Name. - �:. _:..:CERTAINTEED
Thickness (inches) 12
ThermaF;Resistance>(R?Value).;', , R38
Loose Fill Type, BLOWN IN:', :. _
; Brand •l'CERTAINTEED "t . .
Contractor's min installed weight square ft 0.615
14 3/4' inches
Manufacturer's installed weight per`square foot'to achieve Thermal Resistance (R -Value) 'R-38
3 EXTERIOR WALL
*• .;
Frame Type
A. Cavity Insulation
Material BLOWN IN
BraInd Name CERTAINTEED
Thickness (inches) 3112
Thermal'-Resitfdhc' (R -.Value) R13
B. Exterior Foam Sheathing
�-
Material
Brand Name
Thickness (inches)
"ThermafResistance (R=Value)
4 FLOOR OVER GARAGE AREA
Material
Thickness (inches)
5 SLAB FLOOR/PERIMETER.
Material
Thickness (inches)
6 FOUNDATION WALL
Material
Thickness (inches)
Brand,Name
Thermal Resistance.(R-Value)'
Brand Name
TherriibI esistance (R -Value); _
Brand Name,
Thermal. Resistarice"(R-Value);
Declaration
I hereby certify that the above insulation wa§ installed, in:the.buildimand the above location in conformance with! the current
Energy Efficiency Standerds, forresidential buildings (Title 24, part 6, .Califronia Code,of Regulations) as indicated on the
Certificate of Compliancg, where applicable. `
2, 3A V. 7/12/01 ' PARAQON INSULATION.
Item #s 'gnature, D dte Installing'Subcontractor•'(Co. Name) OR
General. Contract (Co. Name) OR Owner
Item #s Signature, Date.
Item #s Signature, Date
S,
Installing Subcontractor (Co. Name);OR
General.Contract. (Co. Name) OR Owner
Installing'Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner