0011-189 (SFD)LICENSED CONTRACTOR DECLARATION
. -
I herehy affirm under penalty of perjury that I am licensed under provisions of
Chapt�i 9 (commencing with Section 7000) of Division 3 of the Business and
,:If rofessionals Code, and my License*is in full force and effect.
License # Lic: Class Exp: bate
bate 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, a"s 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. 1.
( ) I have and will maintain workers' compensation insurance, as required b'y
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 GOLDEN MOM INS, Policy No. •
(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 ofSection •3700 of the Labor
Code, l shallkfort6iwit comply with those provisions. ,f
Date:../C u?'Il 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, & 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.
7 P t
Signature (Owner/Ageni)*_6L u
Date b/ yr•
BUILDING PERMIT PERM TN
DATE j� rVALUATION LOT TRACT
! C"f un,1 a14) 2. 27519
JOB
APN
ADDRESS 19-44.9 P. SP3.0 Y= MY
OWNER
CONTRACTOR/DESIGNER/ENGINEER
sr 1ti1T13i .a C" qW ; . C�3v[1'� 1"dd1 i'ili;
C11:f",.A1 U at' OR CMELL COMMUlIfff
1535 3,1V O7I'MY19M, 0200
1535 t3o,1)" VERM, MIR IP9100
SAN BERNA 1)INO CA. 92408
I
SAH BERWA1~`.DII+ 0 CA 92408
`
(509)381-6007 2120 .
USE OF PERMIT
ns woy? WMLY ZMML 912-r
31VO - LOT 2 PL A24 SLRA ;PEItVIT I'i( .E3 N(f 114= 00, ,U0C. <:
Wiii.,iA100Y.dAY''Y'ROAC,Ii DREV9WAY
Tk2.EiCT CONS'MUCTION. 2.13$40 iii'
OAPLAOTYCACi'YOR`.1' CM) 14,220,60 .
nximAm C:i)ir C?1 ConnR :11109f.
13011W.10
PkRhi n, ME bTMVARy
CQXW R11D1'D.ON ME: 101.000-418-000 00M
tYtAN CHECK MrIE 1 d}9-�1CaU-�ui�•:i I t3 $b1.1.43
MECWICAT, ME 101-000-421-000
ELSaFRICAL IFEE .10 3!-00-420-(X)0
i'1aCl%113P�iQ•S�'E�; ' . 1911,Ui+C9.4 i�-000 �P22,'77K
STRONG' PJ OTIf3N'1$EX RIMID 101 -000 -',.,44' -Dai.?
C11?ADMO PER ' 101.000.423.000 $20M
DF."ilELOPER JMPAfT FEZ �1x9Lt�.45i
117p E.
GUB-I'arA& CO:1~fRYRC1'C,710 .:W AN1(�f.13'yi„
. �j3��.�
LOS S d; �4d.�.'nPit.� TD I MR,
'7[ia'1"M P..11m ".1' "'IES DIX-Now
RECEIPT
DATE
By, r' /
y
DATE FINALED
INSPECTOR.
�. h,,6
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 Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
l
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Cf��le+¢
Pool Cover
Sewer Connection
12�?jp o0 �tt1i(
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
(,79-449,PASEO DEME ' LA QUINTA
Number and Street City
Riverside
27519
County Tract No Lot Number
Description of Installation
1 ROOF
Material
Thickness (inches)
2 CEILING
Batt or Blanket Type BATT
Thickness (inches) 12
Brand Name
Termal Resistance (R -Value)
Brand Name CERTAINTEED
Thermal Resistance (R -Value) R38
Loose Fill Type BLOWN IN Brand CERTAINTEED
Contractor's min installed weight square ft 0.615 14 J4 inches
Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value) R-38
3 EXTERIOR WALL
Frame Tvoe
A. Cavity Insulation
Material BLOWN IN
Thickness (inches) 31/2
B. Exterior Foam Sheathing
Material
Thickness (inches)
4 FLOOR OVER GARAGE AREA .
Material
Thickness (inches)
5 SLAB FLOOR/PERIMETER
Material
Thickness (inches)
6 FOUNDATION WALL
Material
Thickness (inches)
Brand Name CERTAI NTEED
Thermal Resistance (R -Value) R13
Brand Name
Thermal Resistance (R -Value)
Brand Name
Thermal Resistance (R -Value)
Brand Name
Thermal Resistance (R -Value)
Brand Name
Thermal Resistance (R -Value) ,
Declaration
I hereby certify that the above insulation was installed in the building and the above location in conformancB with the current
Energy Efficiency Standerds for residential buildings (Title 24, part 6, Califronia Code of Regulations) as indicated on the
Certificate of Compliance, where applicable.
2, 3A \' 7/12/01
Item #s ignature, ate
Item #s Signature, Date
Item #s Signature, Date
PARAGON INSULATION
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (C:). Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner