0011-194 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (com&ncing 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
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.
(j 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 CIOLD9,H F.A(3LH INS, . Policy No. NW- C -9d400-02
(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 Labdr
Code, I shall forthwith comply with•th_osepprovlslons7),
Date: J �'�� 4J Applicant—
_v /
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, 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 inspection purposes.
Signature (Owner/Agent) '� ? 9°�' � /''' '• -'`' Date
BUILDING PERMIT PERMIT#
DATEVALUATION ' LOT W11-494 TRACT
JOB SITE t 7-2,7519
ADDRESS 79-•3W PANW O DM .MY "A -0614M
OWNER CONTRACTOR / DESIGNER / ENGINEER
CENTURY C1tC1WELL COMMY14l; ES CMURY Cnft.OVIELL CO}MsMUWES1
5335 W SQVTRELrr, Wit. 0260 1535 80. *V M M, STK 0200
SAM BEMAMINO CA 9Z408 .0-414BERNAR17 10 CA 9�`d',OR
(909)3831- 007: C I.4 2.120
USE OF PERMIT
sour - LoT 7 Pz pmt 5l.,Rc P1?1tiA a hart 1`SOT iNC:1,.urit kjxxr'
WAi,,t4100I, • 7515 P14SC1•IXCI: ITZE .R&DIT+G,WON FOR Mi9E. rIPJA
ISSUAMCF OF SAME PI A311TYPE
TRACT CONSTRUCTION 2,133.00 "aF
EWIRMI'ED COST 01? CONSMUC.MON
130,160.10
RY
PERI' FEW STMNARY
CONSTRUCTION F
101 -(*0-418-000
� X43 S9D
PLAN CHECK €+” E
$959.11
MECHANICAL FEE
101-000-421-000
LEC t'IUCAIL IrER7
611 »(9t2Cl 1 0 6c'}0
122. 5
PLUMBING IER
101 -OW -i19°000
S122175
S`°CR.OHG MOTION FEZ - RRLSID
102-000-24.1-000
$113.Da
O AOINCI FEE
10'1-000-423.000
'1"ai3.fi3A
DEVZWPER IMPACT FRE
0.TJ -ECTAL C0N3'1Rf?" Tt10N AND PLAN L'&1EM $3,151.63
IMS PFXI -PAW TWO. $0,00
TWAL !" 1�'.fiA1'y.Lf':6':P'M DUVE J° OW 1 $11:51 W
RECEIPT DATE
}1 / BY DATE FINALED INSPECTOR
r t
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 PIN. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
1 coo
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
(j, _� $
Pool Cover
Sewer Connection
f 2a (8
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
Final
Utility Notice (Perm)
INSULATION CERTIFICATE'''
IC -1
_
79-399 PASEO DEL REY.
LA OUINTA
Number and Street
City
Riverside
....• ". 27519', : 7
County
Tact No :. Lot Number
Description of fnstallation
1 ROOF
Material
Brand{Name
Thickness (inches)TermalResistance
(R -Value):.
2 CEILING
Batt or Blanket Type BATT
Brand Name CERTAINTEED
Thickness (inches) ', '12,;
Thermal R6sis4nce.(R-V6lue) -•R38
Loose Fill Type,'. - BLOWN`IN.
Brand CERTAINTEED
Contractors min installed weight square`.ft . 0.615;
' 14 3/4 inches
Manufacturers installed weight per square,foot to achieve Thermal
Resistance (R -Value)`: R-385:'
3 EXTERIOR WALL
Frame Type
A. Cavity Insulation
,Material BLOWN IN
Brand,Name,�' . CERTAINTEED
Thickness (inches) _ 3 :1/2.
Thermal`Resistance (RVal.ue) R13
B. - Exterior FoarmSheathing ^
"�
Material: �
Brand Name •,
'Thickness (inches)
Thermal Resistance.(R-Value)
4 FLOOR OVER GARAGE AREA
Material
Brand Name' _..a•,. .
Thickness. (inches)
Thermal Resistance (R -Value)
5 SLAB FLOOR/PERIMETER
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
6 FOUNDATION WALL
Material
Brand Name.
Thickness (inches)
Thermal Resistance (R -Value)
Declaration
I hereby certify that the above insulation Was installed in the building
and the above location in -conformance with the current
Energy Efficiency St.anderds for'res'iidb'htial,buildings'(Tiile 24,,part 6, Califronia Code of'Regulafions) as indicated on the
Certificate of Complianc , where applicable.
2, 3A
7/1.2/01
PARAGON INSULATION
Item is g'nature, Oate
Instal lin g•8ubcontractor (Co. Name) OR
s
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
installingFSubcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
.-
.F