0002-309 (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
P Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
f ignature of Contra ct6i
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.
k(,)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:
CarrierA �, . � Policy No. ,
Ct9 f_ > ,' L-4101 -1 INS. "P, WC y1?0 1 .111,
(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 forthwith comply with those.pKavjsions.
*!
�C ate: � � -- (Applicants � �
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) _C_ / ': Dat e
PERMIT #
BUILDING PERMIT t� 344 .��
DATE VALUATION LOT L - L "- - TRACT 1ti'3
JOB SITE I A tt. , :±iit ivf-S Hyutw coum APN
ADDRESS
OWNER
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USE OF PERMIT
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CONTRACTOR/DESIGNER/ENGINEER
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E'SITNIATIM C05's 0.1" CONSTRUCTION
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LESS PRE, NUN FIT'S
RECEIPT I DATE I BY /�, I DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
. DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
0.0
Ducts
Slab Grade
-L(_
Return Air
Steel
�j _! _ pp
9
Combustion Air
Roof Deck
S__w
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Insulation
G - - DO
tJ . ti. _ e p
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
V .tti • ��
Drywall - Int. Lath
U -- -
Final
Final <03\ 2
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
o -� OQ
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
u.
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final 4b
Utility Notice (Gas) c 2
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 o
Utility Notice (Perm)
COMMENTS:
Wv-
4t vrG +"k-,tZ
09/26/2000 TUE 14:19 FAX
0 015
INSULATION CERTIFICATE IG1
_ 78-750 ROCKBERRY COURT LA OUINTA
Number and Street Ci,
RIVERSIDE 23895 G1
County Tract No, Lot Number
Description of.lnstallation
1 ROOT=
Material Brand Name
Thickness (inches) Termal Resistance (R -Value)
2 CEILING
Batt or Blanket Type Brand Name OVENS CORNING
Thickness (inches) 12" Thermal Resistance (R -Value) R -38U
Loose Fill Type Brand
Contractor's min, installed weight -square ft Ib Minimum thickness inches
Manufacturer's Istalled weight per square foot to achieve Thermal, Resistance (R -Value)
3 EXTERIOR WALL
Frame Type
A. Cavity Insulation
Material
--Thickness (inches 31/2
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 OW=NS CORNING .
Thermal Resistance (R -Value) R13U
Brand Name
Thermal Resistance (R-Valua)
Brand Name
Thermal Resistance (R-ValuA)
Brand Name
Thermal Resistance (R-Valus)
Brand Name
Thermal. Resistance (R -Value)
Declaration '
I hereby certify that the above insulation was installed in the building and the above location in conformanc 3 with the current
Energy Efficiency Standerds for residential buildings (Title 24, part 6, Califronia Code of Regylations) as indicated on ffi�e
Certificate of Compliance, where applicable. F.SRF�GOIv 1,NSV-ATION Dv
N� 12280 EAST END AVE,
s/zs/oo — pulkiDCA 91710
Item #s Signatureoate Instalifng'•Subcontractor (Co_ Name) OR
General Contract (Co, Name) OR Owner
Item#
Signature, pate
Installing Subcont actor (Co. Name) OR
General Contract ;Co. Name) OR Owner
Item.#s Signature, Date - Installing Subcontactor (Co. Name) OR ,
General Contract #Co, Name) OR Owner
my 1, 1999 -