9909-089 (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
Professionals Code, and my License is in full force and effect.
License 114188 L1�ic. Class Exp. D 14/31119,
e If
/ate, 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:
( ) 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. Jhe
performance of the work for which this permit is issued.
(fig" 1 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 $A09<f-, INS. Policy No. :
(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
subjet to the workers' compensation provisions of Section 3700 of the Labor
Cede, I shall forthwith comply with, those provisions,.
Date: f7• Applicant
/"t.11'/
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 Jo 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.
1SI-
gnature (Owner/Agent)°,f �� 'r{r'/ Date
BUILDING PERMIT PERMIT�(g
i
/ $9t) . 41' 21 TRACT 2399 7
DATE VALUATION LOT
.ql/, /11
JOB SITE ' 45-740 C'OY.Df>:Ft+l' OK LANE
APN 6".11MO.4316
ADDRESS
OWNER i
CONTRACTOR / DESIGNER / ENGINEER
CEN'Y XY' C:IIr0VY1;LL Ci3M14 UNME.S
Cl±'?JWR'S'CR(+cia�'�r�ELL(COMMUNI' IFS
1535K). `D" il1�[ EE ria S E. �}" W
15.x:1 SO. `W �31.REF f, +71.1.4200
SAN 13Eit.3+6APLDINO CA 924018
SAN BERNARDINO CA rr",M
(909)31-6007 C€ L# 2120
USE OF PERMIT
SING1X FAM ILY 1M11-IN43T
bk 1J- LQ L 2.1, L V .5A, - .k°,1GIhCR VCl N tVt. V lNQIXi.*-, B3.U[X tV c' U,
OR POCe%.,
`r-RA(:'r CONTI RUC:7'110N 1.,679.00 S
074kACEJC'ARP0t. F 411M 5r
�}��,, �py gyeeyy+� vy� g� G,{)g ,��(� �IWyag7,
i iL' 9.1MI8' � flu SuLtlSVA i 3
. .
CON31' i.T7C'1IONfM 5639.9)
PLAN 4,'f3PTvK FEE 101.000439-318 5530$
-
NX(rl-ANICAL F 111-000-421•'0130 347.00
ltUCTMC;AL FIFE . ' 101-f 00-420-0W $115.61
91,t7t12114.1 Fa,..' 101 -MO -14194M 513.1.73
MC)NQ MOXION FEE RFSID ,163.1 -000 -2'•41. -ON $9.93
C'RA4Z"ING M 101-000-=123- 1120 00
DI-V`4xt.QPFR IMPAA"T:FrE S1,9+07.00
S1113-'1O'1'AL C:i: NS#`RUCMON .AND PIAN CHECK
S3,405.37
%Wo P1. _-PAID FF
$0.00
TOTAL. PERMIT FEES DUENM
S3,403.37
RECEIPT
DATE
By,
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ila 'L - 00 Atz
Ducts
Slab Grade
-
Return Air ^ :~
Steel
3 -7--60
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
, 0 2 _mQj
F.A.U.
Framing
Insulation
.Z,L —0.0
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
. 1-00
Drywall - Int. Lath
, r
Final
Final
C� (D -
POOLS -SPAS
BLOCKWALL
APPROVALS
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
Z - I V
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover -
Sewer Connection
Encapsulation
Gas Piping
Gas Test
$ Cd
Appliances
Final
COMMENTS:
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 o
Utility Notice (Perm)
`N1 V : i
INSULATION CERTIFICATE IC -1
c COLDBROCK LANE LA QUINTA
Number and Street City
RIVERSIDE 23995 �r
County Tract No: Lot Number
Description of Installation
ROOF
Material Brand Name
Thickneee (inches) Termal Resistance (R -Value)
2 CEILING
Salt or Blanket Type Brand Name OWENS CORNING
Thickness (inches) 12" Tharmal Resistance (R -Value) R -38U
Loose Fill Type Brand
Contractor's min installed weight square ft Ib Minimum thickness inches
-Vi anufacture r's installed weight per square foot to achieve Thermal Resistance (R -Value)
3=XTERIOR WALL
Frame Type
A. Cavity Insulation
Material
Thickness (Inches) 3 1/2
B. Exterior Foam Sheathing
Material
Thickness (inches)
4 RAISED FLOOR
Material.
Thickness (inches)
5 SLAB FLOOR/PERIMETER
�blateria)
'hiukness (inches)
E FOUNDATION WALL
'riaterial
-hickness(inches)
Brand Name OWENS CORNING
Thermal Resistance (R-ValueL R13U
Brand Name
Thermal Resistance (R -Value)
Brand Name
Thermal Resistance (R -Value)
Brand Name
Thermal Resistance (R -Value)
Brant? Name
Thermal Resistance (R -Value)
Declaration
hereoy cert:ty that the above insulation was installed in the building and -the above location in conformance with the current
='orgy Elficlency Standards for residential buildings (Title 24, part 6, Califronis Code of Regulations) as indlcated on the
Cert!r:cete of Compliance, where applicable. r ARr C -0N INSULA 10N CO.
9/26/00 �2?�0 E.$T END AV E.
,,-jk?.•.'-, CA 41710
ItCT Ps Signatur ate Install?Sg'SuEcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
;em #s Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Signature, Date Inetalling Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
July 1, 1999