0011-211 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
�-raessionals Code, and my License is in full force and effect.
{:cense # Lic. Class Exp. Date
1 W.4 Inc
/at' J �- /°Signatureof 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& Prof essionals'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
201
ance of the work for which this permit is issued.
have and will maintain.wo�kers' compensation insurance, as required by
Son 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensatiort insurance carrier & policy no. are:
Carrier Policy No.
00I.DF-N FAME 1NS.
(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
subje to the workers' compensation provisions of Section' 3700 of the Labor
Co e, I shall Mtkith •comply with those provlslon's?
Vide: ✓ l'C•% Applicant
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, A 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
construgtPon, and hereby authorize representatives of this City to enter upon
the ab6ve-mentioned property for inspection purposes. f
'7,- , c'(: {iii
8i nature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT' •� TRACT
27319
JOB APN
ADDRESS 7,9 420 PAN.W.'O DTX REY,
OWNER I CONTRACTOR / DESIGNER / ENGINEER
CENTURY CRO ;LL C0.1,61WMSMS G7r.'�i'.CC RY C'1Z.OW112.I COMMU ''1
133w sn aiDa oliwsr, uJI'.i:" ono 1535 SrAl Do IRMEXr, EWE, 0100
SM BMIWARDWO CA 97408 SAW P&PWARD190 CA 92408
�S?1jslati�lt}7. C13L4 2120
USE OF PERMIT
SFD - IbT 70 PLAN. 73RD PERMIT I:Tit"SES NOT INCLUDE &OCK
'6'lyAlaiAPOOL 7576 PI.A,NC.l•'tWK IFEM R&MICT ION FOR WAVLE
ISSUANCE Or WILME PLAAIT,'YP E
TRACY' CONSTRUCTION. 1,6/5i,@0 3F
POi'vOHIPAT1O &i.00 SIP
OAIA.+:lMA"ORT (ST 8,1` %20
. '..'s.�A.'Y,l.i
�4�.���y.VA� N4.%+Y7S.�01•�lv�ii
�. M+G/�'1�•�Y.
CONSTRUCTION PEE
101i.000-418-000
$643.00
1'L—AN CHVIICY Pre
tOl�pOo•��� »31;
llt3"3.53
MECHANICAL FEE
101.000.421-000
$53,50
Bl.i?d,UIC:.AL FEE . _ ,
1.0.1.00 0-420-600
�i�J cel
MiIl41'GMA "Z,
101-000-419-000 p-000
S1 X"
9ACI ION FEE - ?ESLD
101-000-241-000.
$10.t1S
ORADINO VER
.101-000-423-000
noxo
DWELOPER IMPACT FZB.
$1�9t1!74I0
'Ci 3-lYY1:AT. `C3.ti�i " Z3d i[ T A�1a11 k�l Li3 $2,996.46
LEM YIFIRF-PAIDY -3 $0.00
-70*M. FEADA.: ' %, F Pl D E NOW, . AJjYR� A"YW
RECEIPT DATEr BY✓'� ' DATE FINALED INSPECTOR
INSPECTION RECORD
` OPERATION
I DATE
POOI/S . • PAS
Steel
INSPECTOR
BUILDING
APPROVALS
Footings
Set Backs
Main Drain
Bond Beam
Forms & Footings
W2,48 1.00
Slab Grade
I (ot
Steel
Underground Electric
Roof Deck
Underground Plbg. Test
Final
O.K. to Wrap
2
_ �-
Framing
Gas Test
Electric Final
Waste Lines
Insulation
Heater Final
Water Piping
Fireplace P.L.
Plumbing Final
Plumbing Top Out
Fireplace T.O.
Shower Pans
Party Wall Insulation
Party Wall Firewall
Exterior Lath
[.I �2
►(� �!b<
Drywall - Int. Lath
W I I..
�. [
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans 8 Controls
Gas Test
COMMENTS:
Final
Utility Notice ( Gas) >/
ELECTRICAL AI PROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures _
Main Service _
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power I —T
Notice
BLOCKWALL �PPROVALS
POOI/S . • PAS
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�lff3 C.s�t��
Heater Final
Water Piping
1-Z 1tPe
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Gas Test
COMMENTS:
Final
Utility Notice ( Gas) >/
ELECTRICAL AI PROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures _
Main Service _
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power I —T
Notice
05/25/2001 FRI 11:35 FAX
1� 005
INSULATIQI
CERTIFICATE
IC -1
79-
!:0 PASEO DEL REY
LA QUINTA
Number and Street
City
70
RI
:irside
27519
County
Tract No Lot Number
.Description
A Installation
1 ROOF
Material
Brand Name
Thickness Inc
Ls)
Termal Resistance (R -Value)
2 CEILING
Batt or Blanks.
a BAN
Brand Name CER7AINTEED
Thickness_ inc
�s} • 12 T
Thermal Resistance R -Value) R-38
Fill DT
BLOWN IN
Brand CERTAINTEED
_Loose
Contractors rr
installed weight square ft 0.615
14 314 inches r
Manufacture)';
istalled weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR W
.L
Frame Type
'
A. Cavity Inst
Material
aon BATT
Brand Name, CERTAINTEED
Thickness
aches 3 112
_Thermal Resistance (R -Value) R-13
B. Exterior Fc
n Sheathing
Material
Brand Name
Thickness
-fiches)
'Thermal Resistance (R -Value)
4 FLOOR OVEI
-3ARAGE AREA
Material
Brand Name
Thickness In,
;as)
Thermal Resistance (R -Value)
5 SLAB FLOOF
'ERIMETER
Material
Brand Name
Thickness in
les)
Thermal Resistance (R -Value)
6 FOVNDATIO'
WALL
Material
Brand Name
Thickness ini�
as)
Thermal Resistance (R -Value)
Declaration
I hereby certify ti
A the above insulation was installed in the building and the above location in conformance with the current
Energy Efl9cienc
5tanderd8 for residential buildings (fltie 24, part
6, Califronia Code of Regulations) as indicated on the
Certificate of Co
31ianc where applicable.
2,3A
4/25/01
PARAGON INSULATION
Item #s
nature, Da
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s
Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner