0011-188 (SFD)LICENSED CONTRACTOR DECLARATION•
Atiereby 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 #a t�. `' Lic: Class Up. Date 9 �Y
P 1411 ed
Date k0W '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, 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. 7()44; Business & Professionals Code).
( ) I, as owner.'of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &.Professionals
Code).
() 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:
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. .
(yE)4 I have and will maintain workers' compensation insurance, as required by
Suction 3760 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 ' • Policy No.
OOIMM FAME IWO, IMC -344069-02 . .
(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 Section 3700 of the Labor
Code, I shallf rthwith comply with those provisions'3
Date:/rf /, %�3�1) APPlicant � 1 �
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 fo the Director'of Building and Safety
for permit ,subject to .the conditions and restrictions',set, forth,. on, Ni
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. employee's.
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)
BUILDING PERMIT PERMIT /t
DATE VALUATION LOT �:'� TRACT
.- i • -
/t �" 9 q t1
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to1
toad -1 � F.r/.5 R9
JOB SITE t i
ADDRESS79 -`Qw7:} rA'2119�✓ DIUI .Yy, Y,
APN
6S6`v-051—�.1 )
OWNER
CONTRACTOR/DESIGNER/ENGINEER
C04TORY MOWIiatil', CK)MMUR!TIM
1535 U0. OV ..' ��C+"! a "1 e60'
1535 SCrr. 'V r`.TMEIrr, 'ETIM 0200
SAN BYAWARMINO CA 9V108
NAiv'B,MIP&DWO CIA 924409
0 } >3x'Piit)dia r -SO 2320
USE OF PERMIT ;
M(H E 17ANCLY DW.rA lv'KO
Sn) n LOT ;i PIA14 3R,PIyI2:It IT WIP 1:8L'f}, 1NO1<tlMO.LDi;t;
WALFA'1e0Y:APPkQACH DIRs99AY
TRACT CaNSTRI1MON 1,6W,008F
PO.RCHIPt}iTIO 24:60 SF
1_1ARA,k1FJ0rA.RP018 6,P) 31173,20
s'
"r OF CONSTRUC,"DON
:a fty
C014S' IZU(tTIOA1 FEE 101.000.418.000 $643,00
1+T1 Alac:HI'=: FUE 1 1-p 14 - 'ts $430.46
MKII ', HIC.AL. FRE W0001. 211.000E 9.351
igqi99`gtXCpp��'3yy'I��'tt{ip�t�r//y��� 1,{;F . _ 1?IHk'1411e60C 42,0-t�}pYCJ1
3$a1y0�0�:+CRII.
.l"S.a1p1A,rJdl`I\S OC -.YY �'- . %i,!�^4aWCk"T ,S�"ail�'V dif�Qk iv1
;TROi4011117 .100 PEP, _MIO R4k� _Saiff7 :;a 31 OG�9 �.i0.D5
C1RADIWO ! ?E $110100.
DWY',r1'X)PRft iIJ1I~ACT PEE �I,941.aA
b-OLI-TMAL C 0k49;l: 91TC�',€:I0N AM PLAN I'�,kigf.R`
/ :GLti,,1`;3 PPE -PAW FUS
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RECEIPT
DATE•C /rBY �^0y/ /
DATE F.INALED
INSPECTOR
E'� i1 ,l fl 4.1.V .
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
1024 Wo
Underground Ducts
Forms & Footings
i_Z) 2-1100
Ducts
Slab Grade
�_ cccReturn
Air
Steel
1 rt c G
Combustion Air
Roof DeckExhaust
Fans
O.K. to Wrap���
F.A.U.
Framing?v1�,
Compressor
Insulation
3-1►— ��.►c
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_ ZZ k_ 9
Fgca % nt+�s
_
- .Z��
Final
Final
POOLS -SPAS
BLOCKWA4.L A PROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
(I Co
Pool Cover
Sewer Connection
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
'S
Final
Utility Notice (Perm)
05/25/2001 FRI 11:23 FAX
4
,16002
1NSULATIC
4 CERTIFICATE
1C-1
79
159 PASEO DEL REY
LA QUINJTA
Number and Street
City
F
lerside
27519 1--;
County
Tract No Lot Number
Descriptior
of Installation
_
1 ROOF
Material
Brand Name
Thickness (inc
s)
Termal Resistance (R -value)
2 CEILING
$
r
Batt or Slanke
'•'Ype BATT
Brand Name CERTAeyTEEp.
Thickness (inc
is)_ 12
Thermal Resistance (R=Value) R-38
Loose FiII.TYp
BLOWN IN,
_
;Brand CERTAINTEED ;
Cont-ecto?s rr
i installed weight square ft 0.615
14 :/4 Inches
Manufacturer',
istalled weight per square foot to achieve Thermal Resistance (R -Value) R38 '
3 EXTERIOR W
I I
Frame Type
A. Cavity Insu
ition BATT
Material
Brand.Name CERTAINTEED
Thickness I
iches) 31/2
Thermal Resistance(R-Value) R-13
B. Exterior Fo
'n Sheathing
.Material
Brand Name
Thickness (
iches) '_
,Thermal Resistance (R -Value) alue
_
4 FLOOR OVEF
;ARAGE AREA
Material
(Brand Name
Thickness (inc
�s)
(Thermal Resistance (R -Value)
-
5 SLAB FLd6k
MIMETER
;
Material
Brand Name .. p
Ttlidkness
s) -
Thermal Res istance R -Value
6 FOUNDATION
'BALL
Material.
Brand Name
�.
`.
Thicimess Oncl
s)
Thermal Resistance R -Value
Declaration
1 hereby certify th;
7te above insulation was installed in the building and the above location in conformsncm with•the current
Energy Efficiency
,'ande,ds for residential buildings (Title 24, part 6 CalWania Code of Regulations) as indicated on the '
Certificate of Com an whey applicable.
2,3A 4125101 PARAGON INSULATION
Items i attire, Date Installing Subcontractor (Co.. Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, Date Installing Subcontractor (Co. Name) OR 1
General Contract (Co). Name) OR Owner '
s
Item #S Signature, Date r Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
I ,