0002-300 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
CTiapter 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
7 i iiia ti 'i ity sii
�ate.3e2 Signature of Contract.r_,,._,�
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 ine properly, am exclusively contracting wlin Ilcensed
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.
(s 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 / 1 1 -,19A �q 1 (1M Policy No. INVA t 0 .y
.�Lt7�L:.•i��9/C ilrB'ky`�lA. 1�4Y `s i�(li)c1-�`/t
(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 those prov' ions.
Date: ., i p Applicant—
Warning:
pplicant 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 purposes.
Signature (Owner/Agent) -` / Dated )
PERMIT #
BUILDING PERMIT
DATE VALUATION p f LOT ''t TRACT 3,1145-01
QO
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ADDRESS , r>i1C�iik
11,011-
nc - A ) „
OWNER
CONTRACTOR / DESIGNER / ENGINEER
f i k''1"rtiAf !�'iael\it1-,3j Is rr�0NA11 ��T 11eIf'1`p.1-,
�Rl�flF. }fi )�I.f.�Cit"Ij)1�1.•. A•Rl i4 N+
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USE OF PERMIT
Sail •d..o.d 421 1'1.AN AiC :,vi_-tdk4e ). 1)1,'l za k ±°:,11 Sk k,'WM7 iLtJi'K 1"3F11 !t.`1 OR
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`rr,aCT( ,.�3TTAW%'°CI0N 1.6716) SF
41
IMSTI ;;ATED OF CONSTRUCTION
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
b ^�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
,g -ZS:Zgv
Ducts
Slab Grade
Return Air
Steel
3 ,Z —®p
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
-1 _ LW
F.A.U.
Framing
�.-�; ..491b
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final �
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 — t'1 _@.m Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
-'j -dw 119Pool
Cover
Sewer Connection
--z Cko CR'F-;l—
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final o
Utility Notice (Gas) c
ELECTRICAL A PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 100
Utility Notice (Perm) pp .�4
COMMENTS:
09/26/2000 TUE 14:16 FAX
INSULATION CERTIFICATE IC -1
78-745 ROCKBERRY COURT LF. QUINTA
Number and Street
City
RIVERSIDE 23995
' Court r22�0..,
Tract No: Lot Number
Description of Installation
1 ROOF
Material
Thickness (inches)
Brand Name
Termal Resistance (R -Vale)
2 CEILING
Batt or Blanket Type Brand Name OWENS CORNING
Thickness inches 12" The Resistance (R -Vane) R 38U
Loose FIII Type Brand —"
Contractor's min installed weight square ft Ib Minimum thickness
Manufacturer's installed weight per square foot to achieve Thermal Resistance (R Value) . inches
00,06
3 EXTERIOR WALL
Frame Type
A. Cavity Insulation
Material
Thickness (inches 31/2
B. Exterior Foam Sheathing .
Material
Thickness inched
4 RAISED FLOOR
Material
Thickness es
5 SLAB FLOOR/PERIMETER
Material
Thickness Inches
8 FOUNDATION WALL
Material '
Thickness •(inoh -s)-
Brand Name OWENS CORNING,
Thermal Resistance(R-Value) R13U
Brand Name
Thermal Resistance (R-VaI�
Brand Name
Thermal Resistance R -Value
Brand Name
Thermal Resistance R -Value
Brand Name
Thermal Resistance (R -Value)
Declaration
I hereby certify that the above insulation Wes installed in the building and the above location in conformance with the current
Energy Efficiency Standards for resldential buildings (Title 24; part 6, Califronia Code of Ragulations) as indicated on the
Certificate of Compliance, where appli0able.
PARAGON INSULATION GO,
s/Z6/00 12280 EAST END AV
Items Signature ate T �91710
DAV
Installing contaactor• (Co. Name) OR
General, Contract aCo. Name) OR Owner
Item s#Signature, Date
Itemltem #s
Installing Subcontractor (Co. Name) OR
General Contract (✓o. Name) OR owner
signature, Date Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
July 1, 1989