0007-149 (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 # Lic. Class Exp. Date
�� 7141"8 B �.'7 �.� 10/31/2c
VDate! f/ Signature of Contractor,rd'',�
p . ,
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:
CarrierGO1.DIN FKAt'3J.E W9, Policy No. NWC-544069-02
(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
Dode, I shall forthwith comply with those provisions.
ate: % I`7> It -1 ' Applicant ,+ Vl
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
te above-mentioned property for inspection purposes. '
r %
Signature (Owner/Agent) t Date
4il ' ' BUILDINGPERMIT PERMIT t1
DATE VALUATION LOT ; Q0� i' 4 TRACT
�Xd1'Tii.�0 3t� 27519
JOB SITE
APN
ADDRESS 79-281 P.l31�Ki.►:��A W ITI A �
a7�eixi7r
,.W4 -0614W
OWNER
CONTRACTOR/DESIGNER/EN (NEER
CMURY C-R0VMI, CO t�-S
CFNTMYCR0W=C0MWU=W
1533 30. "D' MTJW, E01. 0200
1535 SO. wDa MU W, STE. 4200
SAN JBMIARD NO CA 92408
sm BZ1iWAi'tL9WO CA 42408
(909)381y6007 MO. 2120
USE OF PERMIT
SI'D- LOT501 d SRA PERMIT DOES NOT BLOCK WALLS OR
POOL, i
TRACT CONSTUC ION 1,118.00 SF
PORCH/PATIO 40.00 SFS
0ARAMICARPORT (31) . 13,622.00
CON3'TRUCTION FEE 101-000.418.000 $667.50
PLAN CHECK M 101-000.469.318 $551.93
MECIIA14ICAL 7EZ 101.0.00-421-000 $47.00
ELFXTR1C'AL FEE 101-000-420-000 $122.59
PLU1t6MO FEE 101.000.419.000 SIU1173
STRONQ MOTION FEE - REMIr3 101-000-241-000 $10.73
CRADINO FEE 101-000-423`000 820.00.
F3LVELOPLR IMPACT FEE $1,907.00
SUB -TOTAL C,ONS'TRUC4710H AND PLAN'OSECK
U33 PRF,-PATD
$0,00
9 MIX MW
S5,45536
RECEIPT
RECEIPT
DATE
DATE FINALED
INSPECTOR
7�T
C
5
INSPECTION RECORD
OPERATION
Final
I DATE
1
INSPECTOR'
BUILDING APPROVALS
Footings
Set Backs
$
Approval to Cover
Forms & Footings
Equipment Location
Slab Grade
Underaround Plba. Test
Steel\Z
Roof Deck
f 01
O.K. to Wrap
Framing
Insulation
\�Q
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Il�
Drvwall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts .
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Lines
Final Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines (j Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K. for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection 1, 2a _(j0:CbL Encapsulation
Gas Piping
Gas Test I _7X7 _0(100 t, ave--l—
Final
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit ,
Low Voltage Widi
Fixtures
Main Service
Sub Panels
Exterior Receptac
G.F.I.
Smoke Detectors
TemD. Use of Pa
Final
Utility Notice
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underaround Plba. Test
Final Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines (j Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K. for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection 1, 2a _(j0:CbL Encapsulation
Gas Piping
Gas Test I _7X7 _0(100 t, ave--l—
Final
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit ,
Low Voltage Widi
Fixtures
Main Service
Sub Panels
Exterior Receptac
G.F.I.
Smoke Detectors
TemD. Use of Pa
Final
Utility Notice
01/22/01 09:08 FAX 760 346 7276 PARAGON INSUL. 019
INSULATION CERTIFICATE
i IC -1
79-281 SIERRA VISTA
LA 6J INTA
Number and Street
` city
Riverside -
27519
Coun
Tract No —_. _
Lot Number
Description of Installation
j
1 ROOF
Thermal Resistance R -Value
Material
Brand Name j
Thickness (Inches)
_ Termal Resistance (R—Value)-
2 CEILING
Thermal Resistance R-Vah#
Batt or Blanket Type BATF
Brand Name CER�AINTEED
Thicknessinches 12
Thermal Resistance (R -Value) R-38
Loose FII Type BLOWN IN
Brand CERTAINTEED I
Contractor's min installed weight square ft
0.615 Ib Minimum thickness 14 314 Inches -
Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value) i
3 EXTERIOR WALL
Frame Type
Item #s Signature, Date
A. Cavity Insulation
Material
Brand Name
Thickness (inches)Thermal
Resistance (R -Valle)
B Exterior F S tn'
oam ea ung
Material
Thickness inches
Thermal Resistance (R -Valle)
4 FLOOR OVER GARAGE AREA
-
Material
Brand Name
Thickness (inches)
Thermal Resistance('11-Value)
5 SLAB FLOOR/PERIMETER
'
Material
grand Name
Thickness inches
Thermal Resistance R -Value
6 FOUNDATION WALL
Material
Brand Name
Thickness (inches)
Thermal Resistance R-Vah#
Declaradon
I hereby certify that the above insulation was installed in the building and the above location in conformance with the current
Energy Efficiency Sianderds for residential buildings (Title 24, part 6, Calftnia Code of Regulations) A indicated on the
Certficate of Complian where applicable. --
2 1119/01
PARAGON INSULATION
Item itl5 n re, D e
Installing Subco tractor (Co_ Name) OR
General Contra .(Co. Name) OR Owner
Item #s Signature, Date
Installing Su 'tractor (Co, Name) OR
General Contra (Co. Name) OR Owner
Item7s — Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner