0011-197 (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
714188 B ./") 101311 ,
Date' �'�y`f�r "j 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).
O 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'�14aIDD1 FKAOL,S INS. Policy No.. i1613C-�14t1ot3�b1
(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./ f /�
Date:- r / � e`f''�%% Applicant % �i r i> t'. %T C •!'%I�
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 orpursuantto
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 inspectionpurposes.
Signature (Owner/Agent) `` �`•1 �'f "G Date
BUILDING PERMIT PERMT#
DATE { f VALUATION LOT Q TRACT
I ( ! x:' 1.� d e L) $117,8466 (6 d i 27519 .
JOB SITE r
APN +
ADDRESS 79-30 PAR .'O D.Y1, REE
4,1 -AW
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C.EN'd`ii£$.Y Cy}`<,OWE,1. C.14"KNAUNTrIE S
CE1,T1LTIRY CacivrE„t. G".Omma.IN;iEW8
15 015 30. 1X kl `. , L [T'E i 49 OD
1535 $0. °17" UUML S'tL 0200
SA141; ER—WAR.✓WO CA 432408
SAN .BERNARDTAO moi. 92,408
(909)381.6007 GYM 2120
USE OF PERMIT
+ OLY, I?M Y
.%V a LOT 10 PLAN 50S TrlOWI•I' 330EN 140T a14CLl DED AJ. -OC . .
WAIA000L - ^15% PLA NCHOC"K P2I11 EDUCTION FOR M11'L`1'I.Ptd3
TESUANCT, OF SA -ME PLPQbl1rYP9
TRACT C;ONS7RUC`T ION koo& Do BF
PZ:i1i2CWATIO 4&00 SP
OARAGWARPORT ('SIS
EN TIM) coyr 0F.001K,
CONSTRUCTION FET± 101-000-418-000 ?11 t1
PLAN CHWK. F&E i0$.,lSQ(#»4R3 -3'1! Ddti.OQ
R WHAN1CAL "KE 101-000-421-000
LLFC l3ICAL :I ?I:. 100,-0c"20-000 S1 U E2
F'LliltltBYHO PRE 101.0 0.419-000 $146,75
STRONG MOTIOP • RESID 101-00.0-241-000
OTiALiINO FEE 101 •WD423.000 SAO
DIZV LO.PER IMPACP FBF $i,9D 00
IKUB-'A 0T AL CONST :i'1 CIION AND P;I~.AW LWXTK
$3,099.66
)'.�1se3i3 PRE -PAID. FWS
M00
TclfrAll PERM 101999. DUE NOW
RECEIPT
DATE (
BY ,Am /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
_
Combustion Air
Roof Deck
fi
Exhaust Fans
O.K. to Wrap3
C.O"we—
F.A.U.
Framing
3� l� CkrO
Compressor
Insulation
3_(�3 CQ�O�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final >_rJ
BLOCKWA L A` PROVALS
Final
7
POOL. - PAS
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
Z-1
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
1211
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
t►P�
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
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 �L
Final
Utility Notice (Perm) 2
05/25/2001 FRI 11:27 FAX 008
INSULATIC I CERTIFICATE.
IC -1
79
169 PASEO DEL REY
LA QUINTA
Number and Street
City
F
;arside
27519 10
_ County
Tract No Lot Number
Dsscriptior
of Installation
1 ROOF
Material
Brand Name
Thickness (ink
is)
Termal Resistance (R -Value)
2 CEILING
Batt or Blanke
'ype BATT
Brand Name CERTAINTEED
Thickness (in
im 12
Thermal -Resistance (R -Value) R-38
Loose Fill TY p
BLOWN IN
Brand CERTAINTEED
Contractor's rr
, installed weight square ft 0.615•
14 314 inches
Manufacturer':
(stalled weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR W
-.L
Frame Type
A. Cavity In5L
ition BATT
Material ,
Brand Name CERTAINTEED
Thickness
ches) 3112
Thermal Resistance R -Value R-13
B. Exterior Fc
n Sheathing
Material
Brand Name
Thickness lI
iehes)
Thermal Resistance (R -Value)
4 FLOOR OVEF
:GARAGE AREA
Material
Brand Name
Thickness (ink
) _
Thermal Resistance (R -Value)
5 SLAB FLOOR
ERIMETER
Material
Brand Name
Thickness (ink
;� _
Thermal Resistance R=Value
6 FOUNDATIM
NALL
Material
Brand Name
Thickness fink
:s
Thermal Resistance (R -Value)
Declaration
I hereby certify th; the above insulation was installed in the building and the above location in conformance with the current
Energy Efficiency ;tanderds for residential buildings (Title 24, part 6, Califronia Code of Regulations) as indicated on the
Certificate of Corr ian , where applicable.
2,3A �Ri+� 4/25/01 PARAGON INSULATION
Item #s na re, 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