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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 # Lic. Class Exp. Date
/714188 10i.31/201
D — 6;V --Signature of Contractor
atV
OWNER -BUILDER DECLARATION
r
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 ohe 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.
GOLDEN 13ACLE 1N3,
(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, 1 _s. all forthwith comply with those provisio s/
Date: pplicant c'M
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 Qujnta, 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 inspectionr�purrpposes.
S,,idnature (Owner/Agent) r Date
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BUILDING PERMIT PERMI„002-J24
DATE VALUATION 587,372.80 LOT 51 .. TRACT 21995-8
JOB SITE
ADDRESS 43-7a(1 C`.OLDBROOk L ANN APN
OWNER CONTRACTOR / DESIGNER / ENGINEER
reXrriTI) VrN r�a,ri�i r�naanarrnrsr•ttxr �r.�rr,rnti•r,or�zara+r rnRheaT*trrrrr.r
V!•IY A AJ L% l ♦� lA L•4r1„, uV1A tl4 A,\J,l'tl.!l1.Y!) Q. J., 3'Y3 All. J ty tt,YJ 'i. ...L.L: I..�ll Ai�lVI.V l.1,aL.-'
13 3 3 SO. "13” S'1RUEL"1', S1 E, #;200 1535 SC. "D" S11 lr r, 91•E. #1200
SAF. BERNARDINO CA. 924013 SAN 8FRNAR,0f N0 ' CA. 92409
1- -1 (". 9)3.4t -(M7 M4 2120
USE OF PERMIT
sm.LOT 51 MAN 2C -PE iivIT tiOES NGT [NCLUI:L;-BLOCX Wi".9 CA
POOL.
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Nf 1.'R' Rf• •
ACT CO11TR.014
GARiW &C MUIORT 40,00 Sty I
9:s.9i bll Alff"3i 1.•04W O
-
GOFNS•.f•K� li.."f,•ION F*JEE
101-000.418-000
$585
f TAN 0l'o'CK FEF
1011-040-439.315
ext;
rM301AUNT AL 11M
I -004 Ate-W1J
EL1';e RRICAL ITEX
51U7
PJA Ml•11NiJ FEE
101-000-419-000
`1TROt4ri�[G�itr?N'1?I; ►?!l;t0 113,1-(x±•24{-Ij(111
$
C ADING DLII
101-000423-000
SvU
iiEWELOPO 3NIPACT FEE
3007,00
L�l
M7
f-i,i
SU T( 1',k L, t"OU(7710N A:Nr) PT ANT CITEC K � 9t:294 19
ESS PRE-11Aab-.FE-13S $0.00
RECEIPT I DATE
TOTAL PERMff FENS D'UE'Pfi•JW 1 $3,294.3,9
DATE FINALED I INSPECTOR
'INSPECTION RECORD
OPERATION `
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
'BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_ /p A4A
Ducts
Slab Grade
- t'7 . Vd)
Return Air
Steel
Combustion Air
Roof Deck
5-I5-00
Exhaust Fans
OX to Wrap
I _"
F.A.U.
Framing
Insulation
tio(-00
. t,� -60
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
7. z -L- p�
Drywall - Int. Lath
-7 -3 _0Z
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
3. 143±000
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
Appliances
Final
Final \Z
Utility Notice (Gas) \�y
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 \ QO
i Utility Notice (Perm)
COMMENTS:
INSULATION CERTIFICATE IC -1
75 �d0: c COLDBROCK LANE LA QUINTA
Number and Street City
RIVERSIDE 23995`1
County Tract No: lot Number
Description of Installation
ROOF
Material Brand Name
Thickneee (inches) Termal Resistance (R -Value)
2 CEiLiNG
Batt or Blanket Type Brand Name OWENS CORNING
Thickness (inches) 12" Thermal Resistance (R -Value R -38U
Loose Fill Type Brand
Contractor's min installed weight square ft Ib Minimum thicXness inches
;96nufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value)
EXTERIOR 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
Material
'hickness (inches)
E FOUNDATION WALL
°laterial
'h ckness (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)
Brand Name
Thermal Resistance (R -Value)
Declaration
P.ereoy cart:fy that the above insulation was installed in the building and.the above location in conformance with the current
=:orgy Elf
ciency Standards for residential buildings (Title 24, part 6, Califronis Code of Regulations) as indicated on the
Ce^!ficete of Compilance, where applicable. F✓,RAGO\ iNSULA "011 CO.
91 OM 1.2280 C ST END AVE
C�, x,710
Ite^. ps Signatureoatg Install11i4'Su6contractor (Co. Name) OR
General Contract (Co, Name) OR Owner
:em qs 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