0002-301 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
I Fbapter 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
7141$3 B 10131/20(
✓D te'� I '~ '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:'
( ) 1, 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, 9S 6Wn& 6t 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 GOLDEN EA.CLE INS.. Policy No. NWO, 544068-01
(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 of --Section 3700 of the Labor
Code, I§hall fprthwit comply with thos rovisions j"
Date: 3 ' < ` ��Applicant e S `-�~
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 vold 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 j;urposes,
/Signature (Owner/Agent) A- � � Date
BUILDING PERMITPERMIT #
2-301
DATE VALUATION 31161.753.60 LOT TRACT 21995-8
:5,
JOB SITEi�!�l.tl�T!' �.�/UTt'�i APN
ADDRESS -
OWNER CONTRACTOR/DESIGNER/ENGINEER
f+pkP+''T a>V !'�Vn%1rrr T r-417,4NAi TAtF''ti7.0
• .,.,V 0 V14 4 ..I%A\ sS 1.. LIS.. �-e Jl .' '1IL'al♦ -"
1333 SO. NY ,STKU1, STT. 4200
SAN BFKNARU1NO CA 1)24/18
USE OF PERMIT
S1NGLL` 1~AM1L DWELL1NG
t''LC.'LAYTlrVV01>nI1 WIN 4, tr f.IF 1111 fIiV�0,TMiLLgQ
1
-i-A5 so. "D" S"rai'' k1, s -m H200
SAN 8L,'RNAkDJN0 CA 92408
(W)3RI-CM7 t"R1.0 2320
3FD-LQT 23 PLAN 5%3i: -P&a.f7 t DOES NOT T INCLUDE- BLOCK WALLS OR
i'c lt.)f:.. '15",a FLAN C,IAKUK, FFA: RW_-* tlC t'lf )N .FOR MUL•f•iPLE ISSUANCE OF
SAIN& PLAN TYPE,
TR
At_ T CON3 rRUC-*rfJ;4 „,f}�Ct.dO T'
GARAGFiCA1U'01 t' txt;.iri+ ;i1
1INTIMNrED COST OF CONSIRUMOIN
PERMIT 1<EE' SiiMNiit1.R'i
CONSTRUCTION f'kai
101.-000-418-000
$699,W
P3, AN VW.Vg, F'ti r%
t n i .(ir)t)_e3o_a 19
p" ?z
i 9E{".TlANI A), T.• -FT
101 W --4211-M
UX(t flttl:'AL FlXi
101-1300-410-c'W
PIA)WINO' 1 eln
1131-000-411)-000
5134.74
:` Rr`, 1E %1r)T10'P1T'('E
101-1IM..?41,115 t}
11 hq
f
iV1t. Sly
f.A ,,' t LVPhk IIvfl+riC;7. 4:El'
SA"All'ou
AXr 1N PUBLIC P1LAVES
141,88
�
RECEIPT
Sitft'1'tib'r1(.("0N.1ZM41f'"1"ONANT) P1;AN( ffj,f'!:. iia?16
LESS' VRE-4'.1;.'31NO
°f.'i3'rm, PF.Ri ill F1~ K.S 013.E N01V 1 $3,132.36
I , C)
DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
3 _ Z y 1� p
Ducts
Slab Grade
4.6,00
Return Air
Steel
`5 . -L F -pQ
Combustion Air
Roof Deck
j . _L _d
Exhaust Fans
CK to Wrap
. iZ�o
F.A.U.
Framing
�t9Q
Compressor
Insulation
g .
Vents
Fireplace P1.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final � 2
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
27-- CQ
Pool Cover
Sewer Connection
$ ZZ
Encapsulation
Gas Piping
Gas Test
7 .-1- e-0
Appliances
Final
Final o�—
Utility Notice (Gas) (o %
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 P 2
Utility Notice (Perm) oc�
COMMENTS:
09/26/2000 TUE 14:17 FAX
0 007
INSULATION CERTIFICATE
IC -1
78-735 ROCKBERRY COURT
LA QUINTA
Number and Street
City
RIVERSIDE
•23995
23
Count
Description of Installation.
Traot.No:
Lot Number
1 ROOF
Material
Brand Name
Thickness (Inches)
,
Termal Resistance
R•Va�
'2 CEILING
Batt or Blanket Type
Thickness inches 12"
Brand Name
OWENS CORNING
Loose Fill Type
Thermal Resistance
(R-Val'.re) . R -38U
Brand
Contractor's min installed weight square ft Ib
Minimum thickness
inches -7
Manufacturer's installed weight per square foot to achieve Thermal Resistance
(R -Value)
3 EXTERIOR WALL
Frame Tvoe.
A. Cavity Insulation
Material
Thickness Inches) 3112
B. 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 Name OWENS CORNING
Thermal Resistance R -Vere R13U
Brand Name
Thermal Resistanco (R -Vale
Brand Name
Thermal Resistance (R -Valu)
Brand Name
Thermal Resistance (R -Value)
Brand (Jame
Thermal Resistance R - Value
Declaration
I hereby certify that the above insulation was Installed in the building and the above looptlon in conformanc 3 with the current
Energy Efficiency Standerd8 for residential buildings (Title 24, part 8, Cellfronia Code of Regulations) as indicated on the
Certificate of Compliance, where applicable.
• PARAGON IN-DULATtOfJ CO.
9/zstoo. 2aq EAS END AVE
Item #7 Signature ate Inetallin Y o. Name) OR
General Contract ;Co, Name) OR Owner
Item #s Signature; Date Installing Subcont.-actor (Co, Name) OR
General Contract mCo. Name) OR Owner
Item #s Signature, Date Installing Subcontractor (Co. Name) OR
General Contract (Co, Name) OR Owner
July 1, 1899