0011-209 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby I affirm under penalty of perjury that I am licensed under provisions of
C' iapter 9 (commencing with Section 7000) of Division 3 of the'Business and
�,,-Acofesslbnals Code, and my License is in full force and effect.
License # Lic. Class Ezp. Date
I-V j7
A Z1
L
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:
( ) - 1, 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).
1, as owner of the property, am exclusively contracting with licensed
contractors' to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exemptunder B&P.C. for this reason
Date Signature of - Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm unde r penalty of perjury ,one •Pf the following declarations:
I have and will maintain a certificate of 'consent to self-insurp, 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 &'polidy no. are:
Carrier'.Policy No.
00LDM4 SA43LE rJ49, % NW.ir,344069.02
(This section need not be.completed if the permit.valuation is for.$1 00.00 or less).
I certify th . at in the performance . ormance of the
he work for which thi . s permit is issu'ed,
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
the k .
subject to he worers! . compensatioh provisions of Section 3700 of the Labor
Code,.!,
shall forthwith comply with -those proyliions.
.7
Date:j,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, in ' demnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of. this application becor-hes null and vold.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.
61
Date
Signature (Owrier/Agent)/ V
DATE
- . f -
JOB SITE
ADDRESS
OWNER
BUILDING PERMIT
/VALUATION . LOT
PAWK0 I= RFY
CraU LTIRY C, ROWELL COMMU&ITES,
15 3 5 DO. 017° VrRpxt STR 4PA00
SM AM4A1DYNO CA 9Z408
USE OF PERMIT
SINGLE FAMMY L%VTOILDNO
PERMIT#
0911-2- 0 TRACT
27519
CONTRACTOR/DESIGNER/ENGINEER
8M.BERMRT)DT0 CA 92408
(90)381-6007-_ CSLA. 2120
5,FD -WT 68 IPLAN 3RC PERMIT 0600 NOT INCLUD9 RLOCK
WALLMOOL, 751% PLANCHECK ME REDUCTION FOP. MULTIPIA.
ISSLIAOCE OF SAME PLANTYll
TRACT CONSVIUCTION JIMOO sr
PORC,WPATICI 94.60 5F
0ARAGPICA11POIRT (311) M1120
=UUTKID COSIr up COB&
PERMIT FEF. 9UMMARY
CONS)TRUCTION "M
PLAII CHI= "Z
101-000-439-318
$131155
MWCHANICALM
101-000-4-21-000
$515.0
UAC- MCAL MILe
.101-000-420-000
$100,61
PLUMBING".Z.
101d000'419-000
$123.75
STRONO MOTIO'NZ - RESID
101.000-"24 I
(M&DWO FKF
101-000-423.000
,0HVEWPM IMPACT FEE
7. 00
MOB PRE -PAID D =09
T 'AL
Pr,.RM'.r ..M. 8 DUE KO W
RECEIPT DATEBr DATE FINALIED INSPECTOR
4
100.460.10
S2,996.46
$0.00
%J"6A6
INSPECTION RECORD
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
12A2$ I CD
Underground Ducts
Forms & Footings
--auua
Ducts
Slab Grade
f o�
Return Air
Steel
N-�-PI ._
Combustion Air
Roof Deck
2 CZ2_
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
j ZZ
'I!-
Compressor
Insulation
(p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath—
Drywall - Int. Lath
_ _
Final _
Final
(�
POOP. SPAS
BLOCKWA�
7A
OVALS
Steel
Set Hacks
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
( ap
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans'
O.K. for Finish Plaster
Sewer Lateral
I2 �-1 �r{i{1.
Pool Cover
Sewer Connection
,Z�tq
Encapsulation
Gas Piping
Gas Test
S 3
Appliances
Final
COMMENTS:
— —01
.
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 11:34 FAX
10 003
INSULAT101 CERTIFICATE
IC -'1
• 79. :10 PASEO DEL REY
LA OUIr:TA
Number and Street
City
R i!rside
27519
No Lot Number
County -Tract
Description :)f Installation
1 ROOF
Brand Name
Material
Termal Resistance(R-Value)
Thickness Inc s
2 CEILING
Batt o! r Blanke ' a BATT
Brand Name C TE
'•
Thickness n� :s 12
aloe)
Thermal Resistance (R -Value) R-38
Loose Fill T BLOWN IN
Brand . CERTAINTEED
14 314 inches
Contractor's r Onstalled weight square ft 0.615'
Manufacturer' nstalled weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR d
Frame TYP8
A. Cavity Ins .abon BATT
Brand Name CERTAINTEED
Material
Thickness 'nch� 31/2
Thermal Resistance (R -Value R•13
Be� or Frior Fii am Sheathing
Brand Name
Material
Thermal Resistance (R-Valueo
Thicktles` Intoes
h---
4 FLOOR OVE . GARAGE AREA
Brand Name
Material
Thermal Resistance R -Value
mMhldgess Ire , i��
5 SLAB FL00 , PERIMETER
Brand Name
Material�
Thermal Resistance (R -Value)
Th
Thickness I ;yes
6 FOUNDATK .I WALL
Material"
Thermal Resistance (R -Value)
Thlokness i ,hes
Declaration
I hereby certify iat the above Insulation was installed in the building and the above location in conformance with the current
Energy Elden r Standerds for residential buildings (Title 24, part
6, Califronia Code of Regulations) as Indicated on the
Certificate of C iplian , where applicable.
-
2,3A 4125/01
'PARAGON INSULATION -
Item ft 'gnature, Datj
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item r Signature, Date
Installing Subco',tractor (Co. Name) OR
General Contrast (Co. Name) OR Owner
Item #s Signature, Date
Installing Subcontractor (Co. Name) OR
General Contrast (Co. Name) OR Owner