0002-302 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Gtvapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License e'#Lic. Class Exp. Date
.111 1.16 /3 U 2t
i
Dat 1-0 ignature of Contractors ,
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 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:
( ) 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.
<d_',•,fi1..A:
(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 shall forthwith comply with th visions.
ate: �– ! ?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�y'rposes.
,/Signature (Owner/Agent) Date
PERMIT
BUILDING PERMIT�li(�
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DATE VALUATION yi7.� i,�3t� LOT�i�� TRACT ?441 14
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ADDRESS 1�_L.! `tY+ .►l�k fail �C})S�
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CONTRACTOR/ DESIGNER/ ENGINEER
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USE OF PERMIT
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RECEIPT
DATEBY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
7 _®(j
Return Air
Steel
Combustion Air
Roof Deck
-Z.82®
Exhaust Fans
O.K. to Wrap
-11-0A
F.A.U.
Framing
137_Z, -40
Compressor
Insulation
Is . f - CO PLXVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
_
Final 0 3
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
04
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
7-2_
Pool Cover
Sewer Connection
®2Z Ca
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final 0 3
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)
COMMENTS:
09/.26/2000 TUE 14:17 FAX
Z008
a
'INSULATION CERTIFICATE
IC -1
78-725 ROCKBERRY COURT
LA.QUINTA
Number and Street
Cit)
RIVERSIDE
23895 24
CountX
Tract No Lot Number
Description,of Installation
"
1:ROOF
Materiel
Brand Name
Thickness (inches)
Termal Resistance (R-Ve(u:) s
2 CEILING
Batt or Blanket Type
Brand Name OV\.ENS CORNING.
Thickness (Inches) 12"
Thermal Resistance (R-Valwa) R -38U
Loose Fill Type
Brand
_
Contractor's min installed weight square'ft Ib
Minimum thickness inches
Manufacturer's Installed weight per square footto achieve Thermal
Resistance (R -Value)
3 EXTERIOR WALL
Frame Tvoe
A. Cavity Insulation
Material
Thickness (inches) Y1
S. Exterior Foam Sheathing
Material
Thickness inches
4. RAISED FLOOR
Material
Thickness (inches)
5 SLAB FLOOR/PERIMETER
Material
Thickness (inches
6 FOUNDATION WALL,
Material
Thickness (inches
Brand Narne O.W rNS CORNING
Thermal Resistance (R -Value) R13U
Brand Narne
Thermal Resistance (R -Value)
Brand Name
Thermal Resistance (R-Valu,a)
Brand Name
Thermal Resistance (R -Valu.
Brand Name
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 Efficiency Standards for residential buildings (Title 2.4, part e, Califronia Code of Regulations) as iadlcated on the
Certificate of Compliance, where applicable.
PARAGON IKSULATIDIJ 00
12280 EAST END AVE.
t t9
Item #s Slgnature, ��9/2S�100
Ins&lling u colit*ector (Co: Name) OR
General Contract ;Co, Name) OR Owner
Item #s Signature, Data Installing Subcont-actor (Co. Name) OR
General Contract4Co, Name) OR Owner
Item #s Signature, Date Installing Subcontractor (Co. Name) OR
General Contract QCo, Name) OR Owner
July 1, 1999