0002-303 (SFD)LICENSED CONTRACTOR DECLARATION
whereby 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. .
I License # Lic. Class Exp. Date
714186t.' . i•irrli2U0
gate 3, 0?1, ature of Contractor—
OWNER-BUILDER
ontractorOWNER-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 Code). '
(`) l,' as owner of the pr'opeity, am eii Ul iVOY,66htractOg with licensed
contractors to. construct 4e project (Sec. 7044, 'Business & Professionals
Code): t — . • •,) `
() I am exempt under Section B&P.C. for this reason
Date Sianature, of Owner
WORKER'S COMPENSATION DECLARATION.
I hereby affirm, under penalty ofi perjury one of the •following declarations:
( ) I have and.will.maihtain 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
S ction 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. CtCLI%?if.f:f,LL t;v`S. Policy No. Lo�ri'CZ4U5� Ot,
(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 oVS tion 3700 of the Labor
Code,_4hall forthwith comply with th e p ovls,'o , s.
ate 5- 60Applicant
Warning: Failure to`secure Workers'~Compensation coverage is unlawful and
shall subject an employer to criminal penalties^arid civil fines up to $100,000, In
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, Interest and attorney's fees.
IMPORTANT Application is hereby made to the -Director of Building and Safety
for a permit subject to the conditions and .restrictions -set, forth on his
application.
.1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under'or pursuant to
any, permit Issued as a result of this appllcaton agrees to, & shall, Indemnify
& hold harmless the City of La Qulnta, Its officers, agents and employees.
2. Any permit Issued as a result of this application becomes null and void if
.work Is not commenced within 180 days from date of=Issuance of such
.permit, or cessation of `work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above Information is
correct. I agree to comply with all City,'and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentloned property f�orr Inspectioq'purposes.
Signature (Owner/Agent)), Date
BUILDING PERMIT PERMIT#
DATE VALUATION ST.3(1,7.%3.fj11) LOT TRACTJOB
SITE
ADDRESS fL�cr3'aii9t..� S.�i��i$�
APN -
100'e=r3dti-�
OWNER
CONTRACTOR/DESIGNER/ENGINEER
I"17A1"(q r `4+' C+G�/'tit1. i 3 !"•�l!►4A 1 Ct't`7i74�
..,.ry, i h. 4J,,. t �,.... �,� ov �I.: s:t t. gats taSa4lt•e.t 1.41.0
f"+Gis?1 TU' I•�nI' \Rr'C' r f� ��A'( �n'rt 7:C
t.,,. i•. t. a•.t�et f 4.tt.�4C l...i..i,r •,,r�l2f 1s�2.1A't i~i �t.+u
i,535 50a. 017 STR.e r, Sn" #20o
15.33 so. "D" MEET, SIM, Iir00
Std', Bl;tttti AI ' WO) (A W1408
S.A:P0, 3EANAM:1 NO Ok
9'24008 •
fN0> ��f2f-60017 (,'11j,#d
2170
USE OF PERMIT
t
: -.- •.i3O 25 i!WkN SOB DOES 60T YNCLiTOET DLCO;K. 'WALL5 ir,e
POOL. 751Y -o l AN t lWX t•;EE' &f_"-0UCT147JN V(YRZ,.NILIL'.l'1?'IJ, SSUA.NCE: OF
,'A:N.tE PL, NN `1`YP,&
1.110100M 001
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ili: .7533.60-
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MAROV
CO.. NS'1'.t;UtiTION t E �Ui-UUU 4:1.1'6-0001 �tiJN.CrO
,PL AN Ct-f' ('t(.:t= € E !.(I f 4100-4�9-.31 A S144.2-3
N1r1r;1VNN1CAL a"lu; 10S -000'•,461__M
L LLTCPRI AL FEE %U1-0001 tiiZ-UUU $i7z.�1
VLtMfLN04J G FFth" 101-000) 41'? -000 $j X3.75
,
wS'ITCN(}nnO'cTt?'nfRrS'I'D 01-090-2.41-(1106: Vifhg
t,,:;{}UWiNC FL.. i.01-000-423-000 $201.100
Af<T £N .PUBWC PLACES - i1,F,Si.0 701-000-255-000
7IT
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•
21US MRJUA ID a7FEES
11MIM
RECEIPT
DATE
BY ,'
D I /�iyL�
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
—zp'.mp
Combustion Air
Roof Deck
_ *6 WExhaust
Fans
O.K to Wrap
_pp
F.A.U.
Framing
Compressor
Insulation
S•w
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
m"Ll -de
Drywall - Int. Lath
U
Final
Final D
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
$ ZZ,
Pool Cover
Sewer Connection
ZZ FE'9L
Encapsulation
Gas Piping
Gas Test
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 c
Utility Notice (Perm) 00
COMMENTS:
09/26/2000 TUE 14:17 FAX
_ 16009
INSULATION CERTIFICATE
IC -1
78-715 ROCKBERRY COURT
LF- QUINTA
Number and Street
City
RIVERSIDE
23995
County
Description of Installation
Tract No: Lot Number
1 ROOF
Material
Brand Name
Thickness (inches)
Termal Resistance (R -Value)
2 CEILING
Batt or -Blanket Type
Thickness (inches) 12"
Brand Name OMENS CORNING
Loose Fill T
Thermal Resistance (R -Vane R -38U
e
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
Frame Type
A. Cavity Insulation
Material,
Brand Name OV1-ENS CORNING
Thickness (inches) 31/2 ,
Thermal Resistance (R-Value)R13U
_
B. Exterior Foam Sheathing
Material
Bn3nd'Name
Thickness (inches)
Thermal Resistance R-VeILe)
4 RAISED FLOOR
Material
Brand Name
Thickness Inches)
( -
Thermal Resistance (R -Vale)
5 SLAB FLOORIPERIMETER
Material
Brand Name
Thickness (inches)
Thermal Resistance (R-Valua)
8 FOUNDATION WALL
Material
Brand Name
Thickness (inches)
Thermal Resistance (R -Valu?)
Declaration ,
I hereby certify that the above insulation was installed in the building and the above location In conformanm with the current
Energy Efficiency Standards for residential buildings (Title 24,. part 6, Califronia Code of Regulations) as indicated on the
Certificate of Compliance, where applicable. ,
ei2s�oo PARAGON dNSULATION CO ;
Item #sV -
Signator to Installing you a (���I®me) OR
General Co IC Name) OR Owner
Item ids Signature„pate , Installing Subcontractor (Co. Name) OR
General Contract (Co- Name) OR Owna�
.Item#s „Signature, Date Installing SubconCactor (Co. Name) OR
General Contract Co. Name) 0R Owner
July 1, 1999 _
Ka