0008-190 (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
,;�F`eLi
c.roofe5sionals Code, and my License i n Clafull force and effect. Exp. Date
714188 13 1W3112(.
pate N_ Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the ontractor'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
S c ion 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 f OI.DEN EA0X 1143. Policy No. NWC•944058-02
(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 f rthwith comply with th s ovis'ons'
OR) Applicant
Warning: Failure to secure Workers' Compensation c v rage is unlawful and
shall subject an employer to criminal penalties and civil es 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 representati fes of this City to enter. upon
the above-mentioned property f p , p ction purposes (�
Signature (Owner/Agent) Date
BUILDING PERMIT PERMTk
DATE VALUATION - LOT 0-190 TRACT \
7 T7 -C%Uti,13.%iD 55 27519
JOB SITE
ADDRESS 7 2 2.tERuA V�aiiiA.
APN
6.104-461-W9
OWNER
CONTRACTOR / DESIGNER / EN (NEER
MT MY CROWE[J, C0Wi t�Ii`.M,
CWTURY CROWELL CO1v UWI IS
1535 1301 TO almill wym 4.200
1535 SU, TP SITdUL UM 0200
BERNAR.I51A1.O CA. 92408
SAN M;dARMTO CA, 92408
(909)38146007 C`'HL,fA 2120 .
USE OF PERMIT
SIFO-LOT 55 PI.,A14 SLB • PI.F.RfAIT OOM03 NOT INC:14UDE BLOC:K'WAI..L OR
POOL. 1.5% PLAN CHWX FEE i3RP.DUCT10N ICOR MULTIPLE ISSUAPrC9 01f.
SAME PLAN TYPE
TRACT CONSTRUCTION 2,139,00 31?
0ARtACi=A.RPOR'T (SY) 14,229: 0
198',>iMEA rE D COST OF CO:lMURUCnON
130,160.10
P tf.. TFRE 8tThO,d RY
.
CONSTRUCTION FEE 101«000-418.000 r#t1,00
PLAN CHECK .FEE 101-000-439-328 $IM.46
MECHANICAL FEE 101.000.421.000 $'18100
: gAUTRICAL, PEE 101-000-420-000 `1127.79
PL,i)MBINO1i+EE. .101.000.419-000 3181,39
STRONG MOTION IEE • REBID 101-000-241-000 $13.132
GRADING >7FY, F 101-000.423.000
bEVELOPi!I$.:)mPACr IEE $1,907.00
i.j X:i M
Pli`i.
Stro-IX)T.AL CO)AKRUC°Y'id1`1'AND PLAN CBECK
$3,314.48
La" PRE -PAW EMS
$0,00
' VrAt[ff. 8 DUE NOW
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
a..
INSPECTION RECORD
` OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final _
-'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 I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
'Shower Pans
i2 �20
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
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
Utility Notice (Perm)
0'1/22/01 09:08 FAX 760:346 7276 PARAGON INSUL,
INSULATION CERTIFICATE IC -1
79-291 SIERRA VISTA LAdUINTA
Number and Street city
Riverside 27519
County Tract NoroUN—umber-"
Description of Installation
I ROOF
Material Brand Name
Thickness (inches ) Termal Resistance (R -Valu)
2 CEILING
Batt or Blanket T BATT
Brand Name CERTAINTEED
Thickness (inches) 12 Thermal Resistance (R -Value ) R-38
Loose Fill Type BLOWN IN Brand CIERTAINTEED I
Contractor's min installed weight square ft 0.615.1b Minimum thickness 14 3/4 inches
.Manufacturers installed weight per square foot to achiev6 Thermal Resistance (R -Value)
3 EXTERIOR WALL
Frame Type
A. Cavity insulation
Material Brand Name
Thickness (inches) Thermal Resistance (R -Val e)
5. Exterior Foam Sheathing. .1 . I
,Material Brand Name
Thickness (Inches) Thermal Resistance (R -Value)
4 FLOOR OVER GARAGE AREA
Material Brand Name
Thickness (inches ) Thermal Resistance (R -Value)
X.5- SLAB. FLOORJPERIM , ET8R' " ' '.Y,=..' ;) .. ;
atenal Brand Name
Thickness (inches),. Thermal Resistance (R-Valde)
6 FOLANDATION WALL
Material Brand Name
-Thickness (inches) Thermal Resistance (R -Value)
Declara'don
I hereby certify that the above insulation was installed in the building and the above location in cconfo nce with the current
Energy Efficiency'Slanderds. for residential buildings ('Title 24, part 6. C21ifronia Code of Regulations) a[ indicated on the
Certficate of Com Ii h pplicable.
p ian where applicable. K
2 PARAGON INSULATION
Kern #s nature, We Installing Su"tractor (Co. Name) OR
General, Contract (Co. Name) OR Owner
Item #9' Signature, Date Installing Sub tractor (Co. Name) OR
General Contraq (Co. Name) OR Ownir
Item ft Sign2turej)ate Installing Subcotractor (Co. Name) OR
General Contra (Co. Name) OR Owner
18