0011-190 (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
Professionals Code, and my License is in.full force and effect.
License # Lic. Class Exp. Date
Date 1147 //)";/)Signature of Contractor �J J1 "r '
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, of. 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,coritracting 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 ofthe following', declarations:
O 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 iperformance of the,work for. which this
permit is. issued. My worker§' compensation insurance carrier &policy no. are:
Carrier Policy No.
CIOWEN R,Ca.�,.E INO. NVIC . 44069 -os
(This.section need not be completed, if the permit valuation is for $100.00 or. less).
O 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 agre that if ['should become
subject to the workers' compensation provisions of Section 3700. of the Labor
Code, I shalliforthwith comply with those provisions..- ;
Date : `r />;_ Applicant L '�.�' #`. r, , i A0 v!
Warning: /Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $1.00;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_ Applicatiori is hereby made to the Director of Building and Safety
for a permit subject to the conditions . and restrictions se,i 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) �' I Date !'?��1 °i•',.�
BUILDING PERMIT PERMIT#
DATE ( -VALUATION LOT $"� TRACT.
S 27519
JOB SITE
ADDRESS 79--439 PANE0 Dn. MW
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
wC'�€i� y C'.[�Gwt�x:Fwwti, +i�C;'M 1 RI'M
�';k"i' AIRY Y �4ti'�1V",161> CC;4 N N1.',ICA
.x535 Aso; °l7° i�".�t..i•..s'IT SITE, A1,60'..
1�l
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SAN ."t I MRDII10 CA 142408'
alAW�7�� MARDINfl .. , CA 92 4,08
USE OF PERMIT
dill �1 'J1+ F'A.ha$YZ,•'. DWELUNG
-
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V`{A1J.R'30U_'4laaPA0A,C H DkJVKV,?! Y- W%PLANC.UF.. i )�iGS"1'tiw k
FOR MULTIPIX ISSU Ak E ON St1.MZP P.L34T'4 O
TRACT C`arI8TR17CT10.14 OF ,
PORCtVIOATIO 94.01,1 SP
4AkAGE1'CA;KPORS,'.0t 6 (�,I?3.20
1?NDi!L+V M-CR)srOF
CONSTP DI CTION FEE )01 -WO -438-006 964
KA N CHECK FRE 1t31.�ff2�--X39-3�t �i i�l.�5
MECH aNlt,�',��gali'�-a;. �{ji�'"� (i"�r,".��^�� $53.50.
..
ELlyt.TR.lCALYALit . 10-0t1c-42 -000 �Ye►La6�
PLUMBINO RZ BI71.17i
'STYxc 140 b/I0;1ION moi? a PWSID 1,01-000-241"_000 �Yfl.l7�
OR&DING Fkt 1 1.t��0 »7�0(3�3 �2p,4tlh
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VSUS-TOTAT, C.10, M_ IJ MON.AND PLAR 0W.1K.
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RECEIPT
DATE i
BY.�
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
I?k?4 1-00
Underground Ducts
Forms & Footings
—1.2–AIL, --po
Ducts
Slab Grade
_dol � �
Return Air
Steel
Ig,Q
Combustion Air .
Roof Deck
Z� ISP �-
Exhaust Fans
O.K. to Wrap–
F.A.U.
Framing
– 4�
Compressor
Insulation
3�1
Vents
Fireplace P.L.
1
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
3 tZZ fi=t
FinalZ ✓_�
Final
POOL -S AS
BLOCKWA
L A PROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
I
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K: for Finish Plaster
Sewer Lateral
f21�•'S .cs0
Pool Cover
Sewer Connection
_� t •�j
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Finale
Utility Notice
(Gas)
ELECTRICAL AP ROVALS
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 11:24.FAX
2003
INSULATIC
:I CERTIFICATE
IC,1
7&
139 PASEO DEL REY
LA QUIUTA
Number and Street
City
F
.erside
27519
—County
Tract No Lot Number _
Descriptior
of Installation
1 ROOF
Material
Brand Name
Thickness {int
!a)
Termal Resistance(R-Value)
2 CEILING
'
Batt or Blanke
-ype BATT
.Brand Name CERTA.NTEED
Thickness in
12
Thermal Resistance (R -Value) R-38
Loose Fill Typ
BLOWN IN
Brand CERTAINTEED
Contractor's rr
i installed weight square ft 0.615
143/4 Inches
Manufacturer':
istalled weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR W
I_L
Frame Type
A. Cavity Insu
Edon BATT
,
Material
Brand Name CERTAIINTEED
Thickness f
idles 31/2
Thermal Resistance (R -Value) R-13
B. ExteriorFo
'n Sheathing
Material
Brand Name
Thickness i
.tte5)
Thermal Resistance R -Value
4 FLOOR OVER
GARAGE AREA
Material
Brand Name
Thickness ink
;sem_•
Thermal Resistance (R -Value)
5 SLAB FLOOPJ
cRIMETER
Material
Brand Name
Thickness (inc
s
Thermal Resistance (R -Value)
6 FOUNDATION
'BALL
Material
Brand Name "
Thickness (inc
s
Thermal Resistance (R -Value)
Declaration
I hereby certify the
;he above insulation was installed in the building and the above location in conformance.: with the current
Energy Efficiency
randerds for residential buildings (Title 24, part 6, Califronia Code of. Regulations) as indicated on the
Certificate of Com
ance, where applicable.
2,3A
4125101
PARAGON INSULATION
Rem #s 1
ignature, DeVe
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
Item #s
Signature, Date t
Installing Subcontractor (Co. Name) OR
General Contract (Cc-. Name) OR Owner