0011-193 (SFD)L LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 700,0) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
}18 1{}/31/20
4,
Date ZSignature of Contractor'
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from. the C ointractor'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
4 .
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
I(-) 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 he
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,6bor Code, for the performance of the work for. which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy NO.
0011DRN KAOU W,
(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 *Sectibh 3100 of the Labor
Code, I shall'forth&th comply with- those provisiops.t
Date: //Y Applicant
Warning: Failure to secure Workers' Compensation coverage is. unlawful and
shall subjkt an employer to criminal penaltibs 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 bpon.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-mentibned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT
DATE VALUATION LOT TRACT
V519
JOB SITE f APN
ADDRESS
OWNER
lCONTRACTOR/DESIGNER/ENGINEER
CENTURYCROMLI, COMMM-UN I fTli S
1535 80" "DO ffm-Wrgm 4r,400
SAN BEPHARD-4110 CA 97..408 SAU BERgARDWO 'CA 92408
(!409)381,60W MIX 2120
USE OF PERMIT
SINGLE PAMUY DWULNG
SFO , LOT6 PLAN 1H PFRMIT DOME.' NOT 1XCLU1* WbCIK WAIA/POOL
- o
7PY
PLANCHECK FEY, REDUCTION FOR, MWIPLE ISSUANCV, OF EIAMR
PLANTYPP,
TRACT CONSTRUCTION 1,479.00 SF
PCIRCWRATIO '94.00 SF
GARAG WCARPORT (3F) M"120
I ISS'MfATED COST OF CON9).2v cnoiN
IWAWAO
PERW rFEE'WMWARY
CONEURUCTION FFA
103.,000-41-8.WO
$643.00
PLAN C.HFA.*K PHE
101-000-439-318
9135.53
WXHANICAL FEE
101-000-421,000
0:3150
10-1 -00&4M000'
$100.61
STRONG 1ADTION FFX -.&ESID
101-000-241.ON
ORADINO FRE
101!,000-423-000
DEVERLOPETt ITAFACT ITZ
KYJ--TOTAL C0AY1XEJC1T0Y. ANDIX" CEIECK. $2,996.46-
I -Ess FIRE -PAM.F= $0.00
I
J DTAL PEMKIT M. . Is DUE NOW
RECEIPT I DATE
DATE FINALED
I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I , Z� l�
Underground Ducts
Forms & Footings(
l eJpo}�
Ducts
Slab Grade
Return Air
Steel
pl
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
c3�_ r-
F.A.U.
Framing
13 C
Compressor
Insulation
Fireplace P.L.
I
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
_
Exterior Lath
Drywall - Int. Lath
e�
3 t2s o C dam
Final/
Final
POO4S - SPAS
BLOCKWAI.L
PPROVALS
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
12if 1,00-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
t.� (sap r
Pool Cover
Encapsulation
Gas Piping
Gas Test
3
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels _
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
05/25/2001-FRI 11:25 FAX
0005
INSULATIC
d CERTIFICATE -
IC -1
79
109 PASEO DEL REY
LA QUINTA
Number and Street
City
F
erside
27519
Coun
Tract No Lot Number
Descriptior
of Installation
1 ROOF
Material
Brand Name
Thickness (in r
s)Termal
Resistance(R-Value)
2 CEILING
Batt or Blanke
Fype BATT
Brand Name CERTAINTEED
Thickness Onc
12
Thermal Resistance(R-Value) R-38
Loose rill Typ
BLOWN IN
Brand CERTAINTEED -
Contractor's rr
1 installed weight square ft 0.615
14 314 inches
Manufacturer.
/stalled weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR W
I.L.
Frame Type
A. Cavity Insu
,Fon BATT
Material
Brand Name CERTAINTEED
Thickness I
:hes) 3112
Thermal Resistance (R -Value) R-13
B. Exterior Fo
-n Sheathing
--
Material
Brand Name
Thickness (
��
Thermal Resistance (R -Value)
4 FLOOR OVER
:IARAGE AREA
Material
Brand Name
Thidkness (inc
is)
Thermal Resistance'(R-Value)
5 SLAB FLOOR
E.RIMETER ' ; -;-
Material
Brand Name �
Thickness (inc
;s)
Thermal Resistance (R -Value)
.6 FOUNDATION
''BALL
Material
Brand Name
Thickness (incl
Thermal Resistance (R -Value)
Declaration
�
I hereby certify thi
he above insulation was installed in the building and the above location in conformance current
Energy Efficiency
with the
;anderds for residential buildings (Title 24, part 8, Califronia Code of Regulations) as indicated on the
Certificate of Com
.ance, where applicable..
.2,3A4/25101
-
PARAGON INSULATION
Item #s
na re, a -.
Installing Subcontractor (Co- Name) OR
General Contract (C.). Name) OR Owner
Item #s
Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co'. Name) OR Owner
Item #s
Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Go. Name) OR Owner '
r