0002-305 (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
Signature of Contracto�_,
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 & Professionals Cade),
( ) 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:
( ) 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 performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
,Iti�L1;, IN"'.N'r`t`�`.` 5-I4063=01
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions o�f�Section 3700 of the Labor
Code_las�hall focthwi$Wrnply wits tl� ;fir Y Ions e
'pae.;2 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 p rposes.
Signature (Owner/Agent) 4�'� Date
BUILDING PERMIT PERMIIf#�lJlt
DATE j VALUATION S1 353.40 LOT �.z TRACT
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ADDRESS("4`-oiL/G
710
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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RECEIPT
DATE
BY r ' /
DATE FINALED
INSPECTOR
_
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 3 -Ld) 00
-p@
Ducts
Slab Grade
- Z -80 OA
Return Air
Steel
Combustion Air
Roof Deckg.
`_00
Exhaust Fans
O.K to Wrap
5-
F.A.U.
Framing
5'-3 L
Compressor
Insulation
,Z .pp
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
mel -
Drywall - Int. Lath
Final
Final _ eo
BLOCKWALL APPROVALS
POOLS - SPAS
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
3- 17-0
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
19 ro vrifte,
Pool Cover
Sewer Connection
1572_ v:414
Encapsulation
Gas Piping
Gas Test
'1 ..-t _d*
Appliances
'Final
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 00
Utility Notice (Perm) .
COMMENTS:
09/26/2000 TUE 14:18,FAX Z011
INSULATION CERTIFICATE= IC -1
78-710 ROCKSERRY COURT LA QUINTA
Number and Street C• ,
RIVERSIDE
' 'Count
Description of Installation
1 ROOF—
Material.
Thickness inches
2 CEILING
qty
23995 C2-7—')
Tract No: Lot Number
Brand Namo
Term al Reslstance (R-ValLe)
Batt or Blanket Txea
Brand Name 67ENS CORNING
Thickness (inches) 12"
Thermal ROSlstancce (R-VaLie) R -38U
Loose Fill TY20
Brand
Contractor's min installed weight square ft '
Ib Minimum thickness inches
Manufacturer's Installed weight per square foot to achieve Thermal Resistance (R -Value) ~'
3 EXTERIOR WALL
f
Frame Typo
_
A. Cavity Insulation
Material
Brand Name OWENS CORNING
Thickness (inches) 3112 -
.
Thermal Resistance (R-ValLe) R13U
8, Exterior Foarn Sheathing
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value
4 RAISED FLOOR
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
5 SLAB FLOOR/PERIMETER
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Value)
6 FOUNDATION WALL
Material
Brand Name
Thickness (inches
Thermal Resistance (R -Value)
Declaration
I hereby certify that the above insulation was installed in the building and the above location in conformance with the current
Energy Eff/clency Standards for residential buildings (Title 24,
part 6, Califronla Code of Regulations) as indicated on the
Certificate of Compliance, where applicable.
..
INSULATION CO,
`p�,RAGON
9/25/00
12280 EAST END AVE.
Item #s - Slgnatu , ate
Inatal lln Y C Name) OR
General Contract 'Co. Name) OR Owner.
Item #s Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract C --o, Name) OR Owner
` Item#s Signature, Date
July 1,
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner