0011-195 (SFD)LICENSED CONTRACTOR DECLARATION
I ereby affirm under,penalty of perjury,ti�a't I'a'm—'IiicWWsTd:'�Ad6r.provisions 60-A
,Chapter 9 co'mmenci 'S� - iori 7600y'6f Divii&` 3'6f tK6'B
66 %kith ct usiness and
Professionals Code,,and �n-y License is in full I 6`ice and effec. -
icense
U6'Class ' 7k- . Exp Date, 1
B
4
Date Contractor r1l %
Signature of
OWNER -BUILDER DECLARATION
.I hereby affirm - under , penalty of perjur . y - that I am exempt from the Contractor's
'-License Lawifor the following reason:
'i -s owner r' o f the p roperty';-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, B6sin.e'S-s& Professionals. Code).','.
1,-:7as- owner -of thie`-prope-rty,':a m.'exc.lusively.,contracting with licensed
_
contractors o',"construct ' the'project,(Seb.�.,7044,: Business & Prof essionalg
'
:%�
,..,(),'.l'am'exemptbnder Section B&P.C. for this reason
Date ti Signature of Owner
�,:-4WORKER'S COMPENSATION DECLARATION
I hereby iti
affirm under.pena y,.o perjury'one 'one of the. following deciarati6n
S..
•
.; ' - -','" * ". , -
have and will maintain a certificate -of consent to self-irfsure-for workers'
Labo
d for. C Section 3700of •the7 r Cod6, *for the
compensation," as -provide y Sectio
jp�.rformance of the work for which this permit is issued
1 Kive and will-, maintain workers' compensation.. insurance, as required by
,�,S,��iion 3700'6f the Labor Code, for I the performance of the Work for; which 1. this
is:-- '
-
permn :issue . My.workerscomoensation'insurance m'er & policy y n . are:
Carver
-Policy No
COLI)EN AOLE INS -
,
(This section need not be completed if the permit valuation is for $100.00 or less).
certify that in the performance of the- - work for which this pe . rmit is issued;
I shall not employ any person in any manner so as to become subject tothe
'workers',dompe . nsation laws of California, and agree that if I -should become
,Subj6ct to the w-wkers",co'nipensation provisions of Section 3700 of the Labor
Code
aborCode I shall f,orth h corn' with those provisions.,
ply
Date: It -YJ
/4it, ADDlicant
'Warning: Failure to secure
cure Workeis' Compensation coverage is unlawful and
shaill 'subject anemployer
n .' employr:to criminal penalties
nalties and civil fines up to $100,060, in
addition to the cost of compensation, damages as'provided for in Section 3706
of the La'bor Code, interest- and attorney's fees. -
IMPORTANT Application. is hereby made- to the Director of Building- and Safety
for.,a'permit subject -to thee -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
anyissued issud as a result of this applicaton agrees to, & shall; indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becom&s 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 (OwnedA6ent) Date
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DATE?, v
_ , % Alt.
JOB SITE -7t',J,
ADDRESS-
A PN
OWNER
CONTRACTOR DESIGNER ENGINEER
3 yet CS 1i
..w
SAN'RER9J=X`IO CA" 92408
SAN Br-ANAP01IM". 19- 09
USE OF PERMIT
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7
SFI:) IAIT 9 PIAN 50A: PD
ERAITT, ES NOT INCI-UDE, BLOCK
VALW100L
Wo mo
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TRACT CONSTKUCTION A
its
PORCHIPATIO 2 4&00
13A1i.AOrIJCAMRT (3k) Ib 173 2Q
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elf"
cosr of coArRuan,
Fva
PEMWIRR 9UMMARM: MIN
CONBTRUCTION FAQ r 101 000-418-000 9-702,504,
PLAN CHECIe FLTr
MECHANICAL AER 101-000-421.-000
WXCTRICAL IWZ, 0-000
PLUM -DING M
STRONG MOTION I?W - M -"ID
GRADINO FRE' 01-000-03.006'
X,
DEVZLDPE.11 IMPACT)FLEF, $1007.09
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. . . . . . . . . . . . . . . .
RTB-!.fiXAL'V-0K9MUCn0X AND Pi-&'
"$3 334 3
LWS MR PAM FUM;
.rarm, rmmi, I-EFs
$3
RECEIPT
DATE,
BY
DATE FINALED
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I� _
Underground Ducts
Forms & FootingsI(,�
Ducts
Slab Grade
2 21a ��
Return Air
Steel
Combustion Air
Roof Deck
I (�
Exhaust Fans
O.K to Wrap
�f �-41
F.A.U.
Framing
-I �3 CltF�
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 3rld !�"
POOLS . S AS
BLOCKWAf
L APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Z 4"o
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Z ($ caCr��
Pool Cover
Sewer Connection
1� t &U
Encapsulation
Gas Piping
Gas Test
S`2
Appliances
Final
COMMENTS:
Final
Z� �ftGv
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
Z�
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
05/25/2001 FRI 11:26 FAX
tNSULATIC i CERTIFICATE IC -1
79 189 PASEO DEL REY LA QUINTA
Number and Street Cay
F ;erside 27519
Descriptior of Installation
1 ROOF
Material
Thickness fine
2 CEILING
Batt or Blanke
Thickness (inc
Loose Fill Typ
Contractor's rr
Manufacturer':
3 EXTERIOR W
Frame TMg
A. Cavity Insu
Material
Thickness I
B. Exterior Fo
Material
Thickness I
4 FLOOR QVEF
Material
Thickness (inc
5 SLAB FLOOR
Material
Thickness (inc
Brand Name
Termal Resistance (R -Value)
"ype BA'I'T Brand Name CERTAINTEED
�!s) 12 Thermal Resistance R -Value R-38
BLOWN IN Brand CERTAINTEEO
1 installed weight square ft 0.615 .14 3/4 inches
istalled weight per square foot to achieve Thermal Resistance (R -Value) R38
I.L
Tion BAIT
! ches) 3112
'n Sheathing
aches)
"ARAGE AREA
MIMETER
6 FOUNDATION 1VALL
Material
Thickness (inc s)
Declaration
I hereby certify th,
Energy Efficiency
Certificate of Corr
2,3A
Item #s
Item #8
Item #s
Brand Name CERTAINTEED
Thermal Resistance (R -Value) R-13
Brand Name
Thermal Resistance(R-Value)
Brand Name
Thermal Resistance (R -Value)
Brand.Name
Thermal Resistance (R -Value)
Brand.Name
Thermal Resistance (R -Value)
the above Insulation was installed in the building and the above location in conformance with the current
`anderds for residential buildings (Title 24, part 6, Califronia Code of Regulations) as indicated on the
lian where applicable. .
4125101 PARAGON INSULATION
nature,Dated Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Signature, Date Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Signature, Date Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
li�006