0011-204 (SFD)LICENSED CONTRACTOR DECLARATION '
I hereby affirm under penalty of perjury that l am licensed under provisions of
Chap&r 9 (commencing with Section 7000) of Division 3 of the Business and
Professio gals Code, and my License is in full force and effect.
Licenseh Lic. Class Exp. Date
7141881 i163 i�7(
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-insurefor, 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.
GOLDF44 EA01,Z INS. - MWO--44968-02
(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. r
Date: ','!r%�/! :`. Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set. forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced. within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ./r� ;'! l r�/^f 'A Date ,'
y -
BUILDING PERMIT PERMIT#.
DATE f VALUATION LOT. 0011."204. TRACT
JOB SITE f %
APN
ADDRESS .19-3501t�'A8.Ia 0 DET, RKY
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Ci+ N T LTRY 1C_R.01VVFL.1...CQmm.umlIV's
�"1'.��$'1" Ry M011^:i L tv'Qmiv1im i 1i
1535 3a, To SIR= um 0200
1:135 30. moi° bmaiwl Sry" '0200
SAGE BKCWJ WO CA 92A08
S.M B19WAR1" INO C.P. 92408
(909 sl -600..7. C.' Ut .2120
USE OF PERMIT
TC11Y, FAMILY DWELLING
3FD - LC3°f' 69 I>Le N 5LC F+WAIT DO.fF,.a NOT INCLUDE BLDCK
WA1.L3i OOL • 7A PLANCHUCK FEEK RRf.1+C�[' C T ION FOR NltYlf TIPLE
ISSUANC& OF S.AMl? PIAN T fPE
TRACT CONSTRUCTION Z13.5,49 3F
0AR A.GWC;A1 RT (S9s)
. .Cae7.Y.ma.We 6•M1Y6°.o.. ort :,r'�/A:.tl��E"r`�1.r�SX4a�•.GA
Dl NG108"4.4'' '
PW W0 FEE: W MARY
CIONST1tUCTION FRU, 101-000.418.000 594�.OED
PIAN CHECK YRZ 101-000-439-319 $163.11
MECHA•W1C AJ1, F99 101m000-421-00,0 "SAVI
ZMTRICA.I. M1 .101 -000-420-WO $122.71
Pl_.tim1 rHo FRE 101 w000-419•000 912 L'A.
STRONO MCM014 014 WX R s D 101-000-241-000 339.01
GRADINCI #7% 101-000--423-000 $*go
L1EVE-I..,i2 ER IMP.1kC S PEP, $1,967.00
BUD- WrAL Cti2dc`1'F`RUC01'10W A9JD PLAN CMC,T
�i S,1 S 1. fid
LF33 P1tH-PXD k' , 3
$0.00
RECEIPT
DATE
BY —
DATE FINALED
INSPECTOR
INSPECTION RECORD
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
C-ee2
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 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
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
1 (H
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
_
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
1•��
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:
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07!16/2001 MON 12:12 FA,1'
7
INSULATIO ,,1 CERTIFICATE
— -=_' 0.1
7C 50 F?ASEC) DEL REY
-- .
71-3;50 ' 'Nurnber and'Street'
City
F .. •erside
2751 g
—� z
Tract No' Lot tJL ether
Count
Descriptio+ of lnstaI atiori
1 ROOF
Material
Brand Name
Tcrrrial`Resistance R -Value
Thickness: in ies
2 CEILING
Battor Blank Toe BATT
Brand Name <. CERTAINTEEC_�
Thickness tr.' ites 12 `
Thermal Resistance R-Valuel. R38
Loose,F.ilLT BLOWN IN
'ft `'
Brand CERTAINTEED
143/4'inche;
0:6'
Contractor's ninstalled'wetgh'tsquare15
installed weight square foot to achieve Thermal, Resistance (R -Value) R-38 _
Manufacture' ; per
3 EXTERIOR i ALL
Frame Time
A Cavity In, leti0n _
Material BLOWN IN
Brand Name •` C.ERTAlNTEEU
Thickness ;inchaa 3112
Thermal Resistancs (R=Value)° R13
B:.Exterior I i5m'Sheathing
Brand Name
Material
Thermal Resistance'
Thicknes cinches)'
4 FLOOR OVI : GARAGE. AREA
Ulateri8l
Brand—Name.
Thermal`.Reststarice'(R-Value) _,.
Thlckness I ;hes)
_!__
5 SLAB FLOC :IPERIMETER
r
Material
Brand Name
Thickness i :des)
Thermal Resistance.(R-Value),____„-_
6 FOUNaATI' IJ WALL
Material
Brand Name
ThermaPResistance (R -Value)'
Thickness !:hes _
Declaration •
I hereby, certiry 'tat the above insulationwas installed (In -the building end the above IoCaiiori to conformance with t�s� �: rrent
Energy Efficier .1 Standerds for:residential buildings (Title 243part
6, Golifronla`Code of Regulations) as indican:c on d t=_
Certificate of C mplianc , where applicable..
Q 7112f01
PARAGON MOLATION_
2, 3A
lnstalling Subcontractor ((;C) -Nr no) OR
nem #s ignature;' to,
General .Contract (Co. Narre) QR Owner
liem #fs Signature,
Installing Subcontractor (^-o. Na ice) OR
.hate
Generd Contract (Go. Name)
Item #!s Signature,,Date
Installing Subcontractor'(C NI:me)—OR
Owner
General Contract (Co. N:cute) nzZ