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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 13 10/3.1./201
DatSignature of Contr ca for=�"
OWNER -BUILDER DECLAR KON
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&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.
N(-/) 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.
c�c�LMN 133,kOLH INS. MVC, :«140;'.0:.1
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that irithe 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 pcovisii s ofSection 3700 of the Labor
Code,.!- hall forthwith comply with t ese� •ovlslons.
kErate: w Applicant�� �+ �
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 oii• 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 propertyfor inspection purposes.
Signature (Owner/Agent)' Date's «
t
BUILDING PERMIT PERMIT
W)2_318
DATE VALUATION $116,753.60 LOT 40 TRACT 2N"_8
JOB SITE—
ADDRESS 4.53-480 C0MBROOK LANE
APN 604 •044)-(I i«
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CT7rT`i` ('Ij V' l�q�ti7T.,t � /"��Y�A,'�'.TY`(1"1`f C
1. l'f t L\ 1 VA\. - .9 4\/ 4 "t". " ALA N
0r-AM'l TO'k, I''1)fW\ V'f I f'*Pl[�.fA'f MTr'r`#:-1
\,-t...i A414 t \.-l\ Y. l..�t,.•yVl Ll,' �llVa?14L.
1535 SO. "D" SIRE "0 SIT. #200
1533 SO. "[7" STREET, �M. 9200
SAN 8.RRNAkf)1N0 CA 92408
StkN BP.K 1AkD.1N0 CA 42408
(909)381-6007 C13L# 21.20
USE OF PERMIT
ti.iNci1,i:FAA11LY L)WhL.WNQ
S -D-1.O i 40 S%Lid4 SCIB11-z^.RERMIT ix:.+i:S NOT NCtrUDE BLOCK WALLS OR
!TOOL. 75:6PLM CHECK 1.1X RW)Ut:l'tC` N FOit NIUL1114,E ISSUANCE 4iF
SAML7,PLAtJ TYPE.
MA4,.i CCIII G! 1 tcLTC,a 10i3 Zuv .Oil S.e
GAkACi&C.ActPORT 416.00 SR
I NT.f.17,L.i'0. 5.DD COS T l/1F CON STRI-1141 ION�lJ>a
1; ERMIT FEE SUNMAR'Y
CONSTRUMON VEE 101-000-418-000 Sb` :Uf3
pt, NW (;tdFCK FEF 101-rl00-43q-'3 19 $144.23
. ,n
q�7,^. �v'.:Y ,tC 7 rte. 10 /y,0 A�„ /{V C���t� nf.
k\'WLiL,t�SS-?Le 1't`A:� 1 V 6 ^V V V `�'il: l "l/ V Si .YY ! 7. It"
I&UM131NG F'k::E $134.75
�• � r , r�
S'1'RON� � NR-Yr!0?4 FFI - .'RFSM 1014,1x) -241 -MO $11)0
c3RAVJNG;TIE $20.00
DRYiZi3T�l i� i.1v11�.± C:T 1 S1,907.tkl
;
ARl' fTd s'LWJC P1,ACES -'.M311`. 701-0(0-2S5-000 `'4. $A1.923
s,,� f
t.A
- ,Q! f13.•'i9nAj, C,ON-17MRUCTf0N AND Af,AN Clip;(iK
S3,332.2 46
!.ESS K1: -1)M, D FI 1'S
$0.00
':x•C)"CAI., i"IM(IN:.flT FEV.',S DUE NO'9V
S3,132.36
RECEIPT
DATE
BY ,d'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
WCombustion
Air
Roof Deck
f — 1Z.40
Exhaust Fans
O.K. to Wrap
o Q= ' ;
F.A.U.
Framing
(V • C L&O
Compressor
Insulation
f S -*Z F'
Vents
Fireplace P.L.
t'
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-201 AW
Drywall - Int. Lath
V • u .
+
Final
_
Final t�
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) o Lo
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 a (�
Utility Notice (Perm)
COMMENTS:
0 024
INSULATION CERTIFICATE IC -1
45-420 COLDBROCK LANE LA QUINTA
Number and Street City
RIVERSIDE 23995 V
Countv Tract No: Lo
Description of Installation
1 ROOF
Material Brand Name
Thickness 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 thickness Inches
Menufacturer's installed 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 FLOORIPERIMETER
Material
Thickness inches
6 FOUNDATION WALL
Material
Thickness (inches)
Brand Name OWENS CORNING
Thermal Resistance (R -Value/ 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
I hereby certify that the above insulation was installed in the building and the above location in conformance with the current
Energy Efficiency Standards for residential buildings (Title 24, part 6, Califronia Code of Regulations) as indicated on the
Certificate of Compliance, where applicable. Pf ,RWGON INSULATIOiV CO,
;?2S0 EAST END t Vir-
9126/00 a" C
Item #s Signatur ate Installing. Su contractor (Co. Name) OR
General Contract (Co. Narne) OR Owner
Item #s Signature, Date Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, Date Installing Subcontractor (Co, Name) OR
General Contract (Co. Name) OR Owner
July 1, 1999