0011-206 (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 acid
Professionals Code, and my License• is in full force and effect.
''^icense # Lic. Class Exp. Date
� / 10/31/2(
Date /':"' �'� Signature of Contractor ��'�"t^
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 F; OLF Policy No. ? (:•544063-02
(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 fo hwith comply with those provisions.
Date: ,%i�'y��i , 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 applicator 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.
BUILDING PERMIT PERMITk
DATE VALUATION LOT .0011-206 TRACT
JOB SITE APN
ADDRESS �.�.� li�i1��0 ���.a � - . �%"�•�.�1-f%13�
OWNER CONTRACTOR / DESIGNER / ENGINEER
CtEM"l.iRY CRO WELL C.'OARWiIMIT313 C1,24 R,Y *RUWBXL L,OMMir"W1rl68
1535 DO, 67 6rRF.M, M 42-00 1535 so, %Y MUM1.9im 4200
Ri Bfir5..1'd`AYDINO CA 924061 SM BER14ARDINO Ch 92408
(909)181.6007 MIX, 2120
USE OF PERMIT
SWOLB FAWLY DWT!11.W(1
Sly%') a L6:'11` 65 .PLAN 2A P RMIT 1DOMS AES '!' INCI,UDE, BIZCK
WAI IAk)OL - 75% P(AMCN&OC'. FEE REDUC` IO14 FOR MUL.TIP14
ISSUANCE OF MME PI AN'TYPE
TRACT Ci NSTFtiJMOTI 11500.09 EF
POIi:C;io PATIO 36.00 SP
OARACIcWARPORT (CD 1%232.W
_q�q'�''ftJA'D C OBIT OF C:C1Ni�. T TC."�OR
(y'j'y�['� /�Ji F.W.-pq
S A`�n.1^.tiYJa d�7FQL7l11TE 1 IM"
CONSTRUCTION PER
101-000-418.000
�50y>OA
PLAN CHECK F99
101 -OW -439-318
suc-"A
A+Ii t;lihlY9IC'.�lL 1F�L
101-000.421.000
11+f°7:t10
1U,XCTRdr_AL VIPF' ;
1317000-.420-000
PLUMBIt1O FE -19
101-00.0-419-000
$127175
STRONG MOTION ng • IMSIO
101-000-241-000
$9.04
GRADING FSR
101,!00042340100
420.00
ummoPER i mPAC`T PEP
34,90 011
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. / RECEIPT
Signature (Owner/Agent), Date �J11 ti t
`.�8s��61•�SiCI
SUB TMX. X. r0148TRM1101 AWA PLAIT CHECK $7,923.691
MID PRE -PMD, MIS S0.00,
DAT BY �%`%� DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I 2 -t -2-11B
Underground Ducts
Forms & Footings
$
Ducts
Slab Grade
1� v( =�
Return Air
Steel
J a�
Combustion Air
Roof Deck
`22 �F�L
Exhaust Fans
O.K. to Wrap
_' �2�
F.A.U.
Framing
Insulation
Ilia
I 2to
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
110*1
Exterior Lath
2 ��
Drywall - Int. Lath
Final
BLOCKWA LOVALS
Finai
Steel
POOLS . S AS
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
12 I g Cp-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
(2� ($
Pool Cover
Sewer Connection
_
I�1$
Encapsulation
Gas Piping
Gas Test
3
Appliances
Final
COMMENTS:
Finale_
Utility Notice (Gas) v/
- ELECTRIC L 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)
65/25/2001 FRI 11:33 FAX
1kLL
Frame Type
A. Cavity In:
ICA
INSULAT101
CERTIFICATE -
-31/2
TKO rm&I-Resistance (R= R-13
7 -7 , , ,
LAQUINTA
70,
'10,046E6,DEL` REE
City
Brand Name
Number and fteet
NORM
R.
27519
Tract 0' Lot Number
Coin
GARAGE AREA'
DesfflPtld r
_,)fln tallat on -
I ROOF
Th l less 0
Brand Name
material
5 SLAB FLOC
Twimal Resistance R -Value I
Thickness in -
material
2 CEILING
Thickness
Brafid'Name .:CE-'-RTAINTEED
Battair Blanks
T/pe BATT
1 -38
Son L e`(FValuq) R
cT
Thickness lnln,
es p: ` 12
IiF A INTEED
Loose Flll T
Contractor's -i
BLOWN IN
ft Thermal
_L_.;L4 3/4 inches
_
(R Value) R38,
ManufaidWrs'
installed weight per square foot to achieve :Resistance
f
[a001
3 EXTERIORN
1kLL
Frame Type
A. Cavity In:
!ation BATT
Br6ndName ."CERTAINI-F-ED
Material.
171ak—nev.
-31/2
TKO rm&I-Resistance (R= R-13
;Inches)
'
Ef Exterior F
am
Brand Name
Materldl
Thigrrijal,Resistancek-value)
!inches
4 FLOOR OVI
GARAGE AREA'
Brand,
material
-Th-drmal.:Resistance
Th l less 0
5 SLAB FLOC
tlPERIMETER
Brand Name
material
Thermal lRetiet,,Ancd.(R-Value)
Thickness
i.hes)
6 FOUNDATI
'y WALL
Brand Name
material
Thermal"Resistance {R -Value.
ThicknessA
;has)
oeclaratior
I I . .
lnsuletd"n'� installed zin-0e buildlng-
and the above':.locqtic1n:in -conformance with the current
I he r eby car t'
jai the above was
Stan Stan demis for r6sjdeijtl6l buildings Moe 24,part,k.6af
ifronia pode,df--kegulations) as in dicated on the
Energy Eftia�
Cerifficate,of C
y
irriplian wtiere applicable:?'
.4126101
PARAGON. INSULATION
2.3 A
l6stalling-Subcontractor (C., Name) OR
iter"s
General Contract (Co. Name) OR owner
Item Signature; Date
Installing;Subcontr.actor (Co.,Na me) OR
#6
General Contract (CO. Name) OR owner
Installing Subcontracto OR
sign�ature, Date
itern #3 General contract (Co- Name) OR owner