0011-208 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby aWirm under penalty of perjury that I am licensed under provisions of
,, C,i,apter 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
Date ' % Signature of Contractor 74/
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 COL83EN FA011, INS Policy No. WC -S44068-02
(This section need not be completed if the permit valuation is for,$160.00 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.
Date: / (yro WI !i1 Applicant—
Warning:
pplicant 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, indemnity
& 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),,," 4" X_'. I M/. Ai Date Zb � /C_ 4.'
BUILDING PERMIT PERMIT" -
DATE V LUATION - LOT .�'
TRACT .
67
2,7519
JOB SITE _ -
APN
ADDRESS 79,390FAM'CiV1.,Y
tD�^
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C:FNI.tiRY CRt3iN"!lLL 0C)M 6UN.€'i1ES
C WNTURY C.i(eMa,,1, CC11viMUN)"'MIS
15.35 30. 'D° SMni" ; MX WOO
J;535 $0, "E0 91R 1 7T, MZ ft00
BAN 13:KMARDINO CA 92408
SAN BEIMAMINO
CA. 92408
(909;;311.6007
(131-A 711.20
USE OF PERMIT
Mau :t?A,M[7 Y UmullP 1.
SFD - LOT 67 PI. All 3L A P19RIT DOES NOT INCLUDE Ett)C.1M
11UWA.LUPOOL .. 75% 3'LANCHECK R U1)ft(:'I ION FOR IVIIJUNPLE
dSyUANCE OF SWINE Pla,.&N YPE
TRACT CO143TRt7a"T)U14 2F
GA ACIlYCARPORT (S.V)
M -80'r PEE SUMMARY
CC)NOTRUCTION FEE 101-0100-41 O -WO S70;0
PLAN C H9(111C FEE 101 -OW -439-318 $153.1.1
ASEWHAN1CAL FEE 101 -000-42 1-W0 $65.00
ELECTRICAL FLYff
P%131VdP1 o 101-000-419-000
STRON0 ,M OTI®NPRE • RESID 1+01-,000-2A I -11W $43.02
C3RAIDINO F911 101.000.423-000 MAO
DE'tl'i: DPER IMPACT" PEE
811113-'r AL OL`5A1'YCRUC''.t°{lOW .EM FLAW CH1r°.CK
$3, 9. s 1.63
Lus 101M.IPAW ..,3
$0.00
"Xyl :%L1 IERY—I 4"71141,.i_` DIVIR NO
r'
RECEIPT
DATE
By
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
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
POOLS - SPAS
BLOCKWALL
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
_ $
Heater Final
Water Piping
1� $
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
I aA P
Pool Cover
Sewer Connection
Gas Piping
�trq
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
INSULATION CE
IC -1
79-390'PASEO DEL REY LA QUINTA
Number and Street City
Riverside 27519" 67
County Tract No Lot Number
Description of Installation
1 ROOF
Material
Thickness (inches)
Brand Name .
TerhiM-Resistance (R -Value)
2 CEILING
Batt or.Blanket -Type BATT Brand.,Name_ CERTAIN TEED
Thickness (inches) 12 Thermat;Resistance (R -Value) ": R38
Loose Fill Type-.BLOWNIN Brand .r. ,. CERTAINTEED' :
Contractor's min installed weight square ft 0:61,5 .14-3/4 inches
Manufacturer's installed weightper square foot to achieve Thermal Resistance (R -Value) R-38
3 EXTERIOR WALL
Frame Tvoe
A. Cavity Insulation
Material. BLOWN IN
Thickness (inches) 31/2
B. -Exterior foam Sheathing
Material
Thickness (inches)
4 FLOOR OVER GARAGE AREA
Material
Thickness (inches)
5 SLAB FLOOR/PERIMETER
Material
Thickness. (inches)
6 FOUNDATION WALL
Material
Thickness (inches)
Brand Name CERTAINTEED
Thermal,Resistance (R -Value) R13
Brand Name..
Thermal Resistance (R -Value)
Brand Name
Thermal -Resistance (R=Value)
Brand Name
Thermal Resistance (R -Value)
Brand Name
Thermal Resistance (R -Value)
Declaration
I hereby certify that the above insulation was installed in the. building and the above (ocation.in conformance with the current
Energy Efficiency Standerds for residential'buildings (Title 24-, part 6, Califronia Code of Regulations)'as indicated on the
Certificate of Complianc , where applicable.
2, 3A 7/12/01 PARAGON INSULATION .
Item #s ignature, D to 'Installing"Subcontractor (Co. Name) OR
General, Contract (Co. Name) OR Owner
Item #s Signature, Date.
Item #s Signature, Date
Installing Subcontractor (Co. Name) OR
{ General' Contract (Co: Name) OR Owner
Installing -Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
4