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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
Signature of Contractor T
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.
( /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 ,. h. Policy No. „ ��
L.t:�v JLAGI '�f9. ?+, JAG �"; Guu�O.i
(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_ provisions.
D te: Applicant F
io ftw -
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 ins ecti/on purposes.
tSighature (Owner/Agent) Date-?
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' BUILDING PERMIT PERMI11�002-31z
DATE VALUATION $947,372.80 LOT -14 TRACT?3w}S-R
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JOB SITE
ADDRESS 455-375 iCOLrDURi,: 0 9. LANE
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CFNIaT.Y CROWELl. CC):1;P j.,h.,rr!2S
CT A:' INItY C!:4'11/1.1.L COMMRPRT H'S
1533 SO. R13" s1REET, StL. it.LU1J
1535 SO. ".De STREET, �;I'E. #200
SA. SlatZt tARDINO CA 92408
SAN BERNfiRWINO CA 92403
(90'9)IRI.4007 CIAL# 2120
USE OF PERMIT
SINTGLE FA.WLY DWELLING
51:0 -LOT 34 PLAN 2B-Pi�tMIT DOES NOT iNC1LLTD913LCC . WALLS OR
?00L.. i5% PLAN CHECK K r IY REb-DUCT1C51v` $�tJR t UI. i'iPi.E LSSCfANCE OF
SAME PLANT YTIE,
P
TR,ACr C%NT STi1.UC i10iq 1,4-;0.00 Ss
.
GARAG C." RFOli'x i i.3,iry Si'
"A, U0
CSO S`11 UC:'['10N.F.E9 101-OW41"(9) $585.50
1�T•1�rI! LCC;1�` ff.'r,t(►i ()OQ_ttjU.3i$ 31^?.39
rrf%a..1.�.ruAACJi.. t1� 1�t1;-iif}�-�c•-Q�Q �i,.ut)
ELECTRICTL FE : 101 -Glia -03-000
;P.LLfM131NG FF.t=tit-yea-ate 0e() $128.11S
,3T? NC iut(ITzc>1a PEV..9aE 1E1 �Q7
GRADIt�TG rte: 101 -Goa -4213-M..) 3210.00
L � r
J)UVFf,0PER IN WAAC.T'IFEE 51,907.00
3r.t
AJl3-"fYTrA1, C(7N5"1RU-N-`"?0N AND PLAN f.'HTiCK
SiZ 27 24
LA SS P .E -P iD PEES
$0,00
TOTAt li,F RA11. SEry! OUR, NON
$2,92'1.24
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
3r30 p
Ducts
Slab Grade
-it -to
Return Air'
SteelS-30-co
KkO
Combustion Air
Roof Deck
5--2-00
Exhaust Fans
O.K. to Wrap
S i.t _ 80
F.A.U.
Framing
(,t • (� .
Compressor
Insulation
CL a@®
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath i t.
Drywall - Int. Lath
jy .-Lt_00
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
_ -L , Q o
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
?Z 1,eK
Pool Cover
Sewer Connection
vk7ta_
Encapsulation
Gas Piping
Gas Test
51 C2
Appliances
Final
Final o
Utility Notice (Gas) IcAl
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 c 40
Utility Notice (Perm)
COMMENTS:
09/26/2000 TUE
0 018
INSULATION CERTIFICATE IC -1 _
45-375 COLDBROCK LANE LA QUINTA
Number and Street City
RIVERSIDE 23995 f34
County Tract No: Lot Number
Description of Installation
1 ROOF
Material
Thickness (inches)
2 CEILING
Batt or Blanket Type
Thickness (inches) 12"
Brand Name
Terms) Resistance (R -Value)
Brand Name OWENS CORNING
Thermal Resistance (R -Value) R -38U
Loose Fill Type Brand
Contractor's min Installed weight square ft Ib Minimum thickness Inches
Manufacturer'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 FLOOR/PERIMETER
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 Standerds for residential buildings (Title 24, part 6, Califronia Code of Regulations) as indicated on the
Certificate Of Compliarice, where applicable,C
c
F'hRAGON INULAi IOid O.
9/26100 12200 EAST Ei40 AVE.
Item #s Signature ate Ins lT,;w b 6 tra' or (Co, Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, pate Installing Subcontractor (Co. Name) OR
General Contract (Co, Name) OR Owner
Item #r Signature, Date Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
July 1, 1999