0011-196 (SFD)N
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LICENSED CONTRACTOR DECLARATION' �.` - a u-tPERMIrN
'fet-1 •p`J''S5 S L kms; k � � - }. -a•,� � 1
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'RJl hereby affirm under penalty,of penury that I`am licensed under•provisions of T'a f r +
BUILDIN RM • .."
��, r•., ., ,,,..: $h�/ �_ T _.
..m s.:,..te i ll, 7 .yq,7.^r?: 'v -a -, i. "7 .7.. 't31►1 ]•• 1
- Cha ter.9 (commencing with Section,7000 of Division 3 ofahe Business and ,�. f .:v w, TRACT.Y:,*',,;,
, , P ( g ). + DATE t +� ;+, _ � VALUATION k ••ir��S.,Skti S�•+�,,,• • � ,�. LOT, ,, f
r n effect. Z 4 . • 1 E•1 �..?�� �7, ; , r.' ^ t r5':: • k-•1 • rxi 1 Y * f?a ref 1a f
:;`Professionals Code, and my License is in full fo ce' and x 4 .r; , <. s •ys .dry, gel �3f! n, '.??51 r9
License ti ' `r' . Lic. Class "IEx Date ' i + < `� f '' / •r, .. s+. x. .a Wlr rr- dl t� _.�h - ...t
S- ° P ..1 JOB SITE: :k. ;.r.•' .+ �'.;,, t >., a x,- .. J. u�xK-; :.i. APN...rufz.u14yC::`
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ADDRESS'.,i• :{:r5 yr!��i ''B3
7I € �€� r l �1 i _ '39-:379 FA►S+1±.0 Y>' [; i. x,y„ „� to<,. Yrv1. �,' , � ,s+ ,n, &Tz�?=i f�E:•rt,.
u ,... / .. - - -
Date
Signature of Contractor OWNER a V CONTRACTOR/DES IGNER / ENGINEER r� q t
OWNER -BUILDER DECLARATION',, ' M11fRYC.R0 tti. CU AUW4T1E8St 'LI.WT'URY MOM, 'L7C?IrAP+�flN�°is�
-1 hereby, affirm under penalty. of perjury that I am exempt from the Contractor's • 15:5 BE 0'
License Law for the following reason: :' aA,2?1 ksIMf i9W0 I"R�"�a111�;' 0 �'t:i WARM+fL6 *taY�(� ���tjC}fl:
( ) .1,�'as owner of the property, or my•employees with wages as their sole , � e rya�l � • r L Aq120
-'compensation, will do the work,! and the'structure is not intended or offered.for. ,• t, r ` 1 +i #4. j
f!' sale (Sec: 7044; Business & Professionals'Code')-. USE of PERMIT
(.k )til'"as owner of the property, am: exclusively contracting with licensed _ _
rt. A -y.. M .. A'\ywuL'i" r. Y !syiY:4
contractors toyconstruct the protect (Sec. 7044, Business . & Professionals 0 F'°��� •0
Code) -.j c" ` �'b"E� • lAT f! IaL.P�T+t 21�C PT+,�&ilY.la FtifYS 5�10't' ERfGT..ZPi79 f31.D"..t4
( )FI am exempt under Section B&P.C. for this reason *r� y:; �, i • r
Date i ` ~ Signature of Owner i�p',y1�8y3rfC�d�Py�vdgOL-��Ql5��`S�i�7P���}t�PpOjf��{��,'K f,%Z f�k.D[,6t",'lION VOR MULTIPLE
•'ri t47L1'`i/9141�i/f!L' Cf:f'419A dJ i'LA144 LPE k •`k^ ��1 Wyyk ..yy5 ^'�',� '� y. j. }` ' V
... i • .. .: ' ::*,kT.l+i Y v.•5.�+„s k+' �i:fsY,r.+,..+..
WORKER'S COMPENSATION DECLARATION
`.,� try y {reb�... ` �. `r -- . , ' • '. -. - •, - ;..:. �,.. ._ t : � i`l av -Y� +{ Ir {�...x!�,�!� , ,.r
I hey affirm -under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers' TRACT CO�fS'Pf3�7G`1lOf� .. 1,Ri3
compensation, as; provided for by Section 3700f of the Labor Code, for the t?U1tC RKrI0 36 60
'performance of ttie work'for which this permit is issued. Oty,017�{ +t ,°,(,ti}'j°j'
�) ;I,have and will maintain workers' compensation insurance, as required by
.SeJction 3700 of the Labor Code, for the. erformance of the.work for which this
;permit is issued. My workers' compensation insurance 'carrier & policy no. are:
4;,Carver ryq q.}�LY ��jjypryry{{. Policy No. Gip: �e��p�q COS
p�gya�p:§Pgp��7p�yry pgs tem
4r a , kVVttL+JSB� Sw1 AldJw a iRY.S.' 7: VY 4'c�i'4VtJ� Vd4 ' �9y �q qy+q� �i���p {�p7 p E6'Ylt.6tY.l.YY,R.91) i;.tl/Y,ti'Y N•d'dd ^✓9SLWl➢i19I U ,0. <f4Y b �i H� YVJ p8 6✓vV6P '
Y L`FA'dd�!1.56..i3.75, i'r WBY.AI . y ��
k, (This section need not be completed if the permit valuation is for $100.00 or less). ry ��9y�iyyxxyy++ii��yygqsy�t}wo�npETq�y3� 9 /�y�� �1 t g [�Ppat t
- - `.O.iVSTRU4.A 014 FIFE •.I fP1 r=)N41 c8-000
• s ( ) I certify that in the performance of the work for which this permit is issued;
rl shall `not em to - an erson in an manner so as to become sub'ect to the PLAN CHECK FEE 101-0.00.439-318
P y' YP Y J
workers' compensation laws of California, and agree,that if I should become MCCHANICAL RE 101" -000,
`subject to the workers' compensation provisions of Section 3700 of the Labor E:I,.CCTR1C A.L FRE I+�li tl (� eI?.D-000
Code I shall forthwith comply with those provisions.'
PLUMMO > ,s�j�gJ(j(ja$'I9.00O� ����+
. Date , r e - A licant ! i. S'•fti�t�NQ MOTION FEE - ItP.S3D • l baa -tv 00 -?A 1 =f?Dd 4` , � ��;,' $9 f)J ,
! '• Warning: Failure to secure Workers' Compensation coverage Is unlawful and ORADE� O F . , I�3.1 �{3i}iA423 Afit9 , r r. � U>J =' $
`shall subject an employer to criminal penalties and civil'fines up to $100,000; in DFVELOPPFR IMPACT ?E9 � , is $3�9dy"l 00 �
addition to the cost of compensation, -damages as provided for. in Section 3706
Of the Labor Code, interest and attorney's fees. ►x* x
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 V - t '
Ott
application. r"v
1: Each person upon whose behalf this application is made & each person at
P P P P;U-'fCl'X�T,f.�i��3C'U��+@1)1_!'.&V$2 69.'
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 LMS :Prm PAM- , 1 ' f� ' 1$0 �
.& hold harmless the City of La Quinta, its officers, agents and employees.''Y�+M'
.. r
-ITT
permit issued as a result of this application becomes null and void if ``'
Any P PP q.rAL �'` CKW �',n. S DUE NOW.
.
2. An
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., y� ,.
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 4,.My�4"ri_t
the above-mentioned property for inspection purposes. r
RECEIPT 2 DATE' ( t BY P j DATE FINALED INSPECTOR r +
Signature (Owner/Agent) 4 Date
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
430
Underground Ducts
Forms & Footings1_
Slab Grade
Steel
f
�� p �
Ducts
Return Air
Combustion Air
Roof Deck
Z �_
Exhaust Fans
0. K. to Wrap
_
F.A.U.
Framing
�cr Cor
Compressor
Insulation
3 (Z.Z �Z�x
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
_
Exterior Lath
3,p
Drywall - Int. Lath
Faw-r
_
Final d>
.L
BLOCKWA A! PROVALS
Final
POOL -'°PAS
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
I p0
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral
ce
I� —o5-- CQf'�-
O.K for Finish Plaster
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test lol_
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
Final
Utility Notice (Perm)
05/25/2001 FRI 11:26 FAX
INSULATIC 4 C
7C 179.1
Number and Street
F lerside
County
Descriptior of Instaillation
City
519
09
Lot Number
I ROOF
Material
Brand Name -
Thickness (in
Terffia[Resistance'(R-Value)
2 CEILING
Batt or Blanke
'-ype BATT
Brand'Name -Cr:RTAlNTF=ED
Thickness (in
lm) 12
TherMil`Resistanbib'(R,-VdIOe) R-36
Loose Fill Typ
BLO WNJN,
Brand:k ? CERTAINTEED',
Contractoes ry
installed weiigot,s4pare ft 0.615.,
14 3/4 Inches
Manufacturer:
istalled weilht. per sou'are foot to achieve Thermal Resistance (R-Vajue) R38
3 EXTERIOR W
:,L
Frame TO
A. Cavity Inst
Un BATT.
Material
Brand:Name '..CERTAINTEED
Thickness i
iches) 31/2
..ThermalResistAnbd-'(R-Value) `R-13
B., Exterior Fc
-n Sheathing
Material
Brand Nime-,
Thickness i
fiches
Thermal Resistance (R -Value)
4 FLOOKOVEF
3ARAGIE AREA
Material
Bland Name
Thickness (inc
':is)
-":-TheftnafR6sistandeCR-Value)
5 SLAB FLOOR
MIMETER
materialrand
Name
Thickness (in
:is)
.,Thtrfti2l'Resistdii6e�(R-Value)
6 FOUNDATION
NALL
Material
Brand;Name
Thickness (inc
Th&maVlResistance (R -Value), .
DeNaration.
I hereby certify th;
the above insuldtion'was installed in the building' and.thb abovo. 166atori In conformance with th e current
Energy Efficiency
'!an*rds for residential. buildings (fide 24, part
6, Califronia Coidle'df Regulations) as indicated on the
Certificate of Corr
lfbn'* where. applicable.
2,3A
4/25/01
PARAGON -INSULATION
Tam is
g atu
9 re, Dalb
Installing Subcontractor (Co. Name) OR
General Contraict (Co. Name) OR Owner
Item ft Signature; Date Installi-ng Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #9 Signature; Date Installing, Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
a
007