0007-145 (SFD)Q! 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 1 , 60/3112(
ate Signature of Contractor
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:
Carver 0t?I:09N.RAOLE fog, Policy No., WC -544068.02
(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 shal'horthwith comply with those provlsions:.y 1 ;
Date: �? l%}s/7s Applicant;'-�afr".:..
P
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
t e above-mentioned property for inspection purposes. ,
/1�
Signature (Owner/Agent) s . Date
BUILDING PERMIT PERMIT"
DATE VALUATION LOT 00074'45 TRACT
S10OX0.10 28 27519'
JOB SITE
ADDRESS 79-2m suam vmxm
APN
1-W9
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CW1°MY C ROWELL COMMUNUI M,
CENTURY C.FtOWELi. COMMUNMRS
1535 00, To amm Um #200
1 60. ° Ii�L1"T, f`r 4200
B• "AR1.+]NO CA, 92,108
t,;J»ltA BEW14ARDWO CA 92408
(909)381=6007 Cly 21710.
USE OF PERMIT
fWGI.Z if'AIEdILY T)V7'1, J, N'Q
S)fD- LOT 28 PLAN 3A P9RMIT DOM NOT 114CL.UDE BLOCK WALLS OR
P004 M PIAN CHECK REDUCTION FOR MULTIPLIi ISSUANCE
TRACT CONOTRUC`YIDN 11670.00 8F
k
PORCHMA,TIO 84,00 SF
AAFLA(IEICARPORT (3F 0,113.20
ESTJMAIXD COYr 01F CON67RUC' ION
100,dt 43.10
FKRAW FEE MW-i'-iRY
COAib1'I UCTIO14 FEF; 101.000-418-000 $643,00
PLAN CHEICK: FEE 101-000-439-318 8i�.35
MECHANICAL FEE, 101.000-421-000 553.50
ELECTRICAL i.EE 1.01-000-420-000
FLUDABINO F EE 101-000.419.000 5120,73
STRONG MOTION FEE - RESLG 101.000-241-000 $10.05
ORADINO PRE 101-000-4V-000 $20.00
i9iiT1 LOPER IMPACT FEE $1,907,00
SUB -TOTAL COAd MUC'TION• AND PLM CF•i'Ei°7C
*(111.46
f.l•.�� FR.E-PAID F
X0,00
pp .,}
fin, ! '�.
Wp
4.
PnWgT.Vq :DtTE NbW
$3,011.46
RECEIPT
DATE
BY
PATE FINALEP
INSPEGTOR
�
ar
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
of
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
8 yzCQ
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
101Z3,Co tt
F.A.U.
Framing
ap CdCZ3A—
Compressor
Insulation
rwl;r�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
11 \ co
Drywall - Int. Lath
Ce�
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/tom
c�7
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
��p
Encapsulation
Gas Piping
Gas TestO,C
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 Q
Final 2 al C9
Utility Notice (Perm) o
01/22/01 09:08 PAX 760 346 7276
PARAGON INSUL, 1614
' INSULATION CERTIFICATE
i ICm�
79-280 SIERRA VISTA
LA WNTA
Number and Street
Clty
Riverside
27519 I C---28 '
_ Coun
Tract No I - L-ot Numbers
' . Pesciripti®n of Installation
i
1 ROOF
_
i Material
Brand Nam® I
Thickness inches
Termal Resistance(R-Valu�
2 CEILING
Batt or Blanket Type BATT
Brand Name CERTAINTEED
Thickness inches 12
Thermal Resistance (fit-Valuta) R-38 -
Loose Fill T22 BLOWN IN
CERTAINTEED I A
Contractor's min installed weight square ft 0.615 Ib
_Brand
Minimum thickness 14 3/4 inches
Manufacturer's installed weight per square foot to achieve Thermal. Resistance (R.Value) 1
3 EXTERIOR WALL
Frame Type
A. Cavity Insulation
II `
Material
Brand Name i
Thickness (inches)
Thermal Resistance R-ValU9
B. Exterior Foam Sheathing
Material
Brand Name
i
Thickness (inches) _
a Thermal Resistance(R-Valu
4 FLOOR OVER GARAGE AREA
Material •
Brand Name
Thickness mehes
Thermal Resistance (R -Value)
5 SLAB FLOOR/PERIMETER
Material
Brand Name'
I `
_
Thickness (inches)
Thermal Resistance R -Valu
8 FOUNDATION WALL
•
`
" Material
Brand Name
Thickness inches
Thermal Resistance (R -Value)
Declaration
r
I hereby certify that the above insulation was installed in the building and the above location in
conformance
Energy Efficiency Standards for.residential buildings (Title 24, part,6, Califronia Code of Regulations) as
with the current
indicated on the.
Cer ificate of Complianc where applicable.
2 1/19/01
PARAGON INSULATION
Item #s nature, D e •
Installing Subca
ctor (Co. Name) OR
• General Contract
(Co. Name) OR Owner
Item /k: - Signature, Date
Installing Subco
cbor (Co. Name) OR
OF
General Contras
(Co. Name) OR Owner
Item #s Signature, Date
Installing Subco
ctor (Co. Name) OR
General Contra
(Co. Name) OR Owner