0003-195 (SFD);N
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 z"s 101120i
Signature of Contractor
r OWNER -BUILDER DECLARATION
7l 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 Policy,No.
GOI.DIrN UAGLI2, INS. NW41C 5440 &°.�•Ul
(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.
Dat :/'a; j7n ./7<-x Applicant—
Warning:
pplicant 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-roeritioned piopeity fful inspeullun pu puses.
Signature (Owner/Agent) 'yi `'� . 1�`^+ fl 6,1 , Date
fes✓ PERMIT#
s a BUILDING PERMIT 0003-191s
DATE VALUATIIYONi $11.7,.846.00 k0T 6,3 TRACT /7v5(�
JOBSITE
ADDRESS RESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
r--CAFTV 10 V rl0()Xyf1T T f1r lk4Ik TA 1flT,G
t%A vew e. ULA ()Xyf.U,_-IAA 1l1V\ � aL.
f �:Ai't"t T�V `�1?f12�r"t�T i !"�1t�s1,/T fAP7't"F PI'
x.. e..a+a. e.r • ,, �a.r tiltllJ'lLLi _0
1335 S0. "D" S" iREET, 91'E. #2110
1535 SO. "D" STRE, 1, $11E. 9200
�;AN ;pit 1.1vARDINO CA
SAN I3EItIdA.1 D)NO CA 92408
f9I)9� K1-t�1�07 C,Bi.# 2120
USE OF PERMIT
ST9 LE FA1YiILY Wkl..L.NG
SED -LOT 43 PLA14 50 PM- 41T DOES NOT INCLUDE Ii>sWKWALL OR
i'43UL. 75"✓a PLAN CHECK. FEE.WDUCTIGN ON i1/. ULTLFL: tSSUANCL OF
SANCH PLAN TYPE.
7RAC T CONrs IRUCTION 2008.00 Si.
PORCM1 OAT t1. 48.00 SF
OA.titAOVCKR.POWr 417,913 $F
&STFRYAT E D CU ; OF CONSTRUCTION RUCTION
1 y'T,845.00
PERMIT PEP, SUMMARY
CONSIT1ZUC MON FE -6 101-000 418-000 $'102.50
PLAN CRExY' 1? F. 1111- IM -439-318 V46.03
NMC11A2,''1CA1 FTM 101 -000 -SIL I "000 $53.50
ELEC"1RIC..L RIF 101-01;x0-420-000 1;14':.12
PLUMbtNti> FrYs. 101-000.419-(Tt)U $1441.75
s
� �-
8RONO AY)TIDN Y -YE - VERO M-C1W24140) $11.78
G1ttll) ING PIX 101 -OW -42 343100
C�EVisiOlal<TZ rfr�il�ikC`r FEE
AkT IN PUBLIC PLACES - RESID 701-000-25+5-400 $44.62
ST: �Fi= COTA!., AND PLAN! N! Gni CK,
'LESS PRE -P. -MD ITE"
'f!:C)TAL PERMl.T FEES DUE NOW.
�3,1S9r�6i
RECEIPT
DATE
BY/
DATE FINALED
INSPECTOR
�Y
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
16—ti
Return Air
Steel
S - 3 ,
Combustion Air
Roof Deck
Z1 ,3up
Exhaust Fans
O.K to Wrap
' t Y.av
F.A.U.
Framing-
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final l� -I_ sw
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
5 - 3 -
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
4. i
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
n A,0
Appliances
Final
Final L�� o� CQ
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 (l
Utility Notice (Perm)
COMMENTS:
3 EXTERIOR WALL
Frame Tvoe
A. Cavity Insulation
Material
Thickness (inches) 3.5
B. Exterior Foam Sheathing
Material
Thickness (inches)
4 FLOOR OVER GARAGE AREA
Material
Thickness (inches)
5 SLAB FLOOR/PERIMETER
Material
Thickness.(inches)
6 FOUNDATION WALL
Material
Thickness (inches)
Brand Name Certainteed
Thermal Resistance (R -Value) R-13
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 Compliance, where applicable.
/27/00 PARAGON INSULATION
Item #s ignatu , Date U Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s
Signature, Date
Item #s Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
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,
INSULATION CERTIFICATE
y
IC -1
79-411 Sierra Vista
La Quinta
Number and Street
City
Riverside
27519 43
County
Tract No Lot Number
Description of Installation
1 ROOF
Material
Brand Name
Thickness (inches)
Termal Resistance (R -Value)
2 CEILING
Batt or Blanket Type batt
Brand Name Certainteed
Thickness (inches) 12
Thermal Resistance (R -Value) R-38
Loose Fill Type blown in
Brand Certainteed
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 Tvoe
A. Cavity Insulation
Material
Thickness (inches) 3.5
B. Exterior Foam Sheathing
Material
Thickness (inches)
4 FLOOR OVER GARAGE AREA
Material
Thickness (inches)
5 SLAB FLOOR/PERIMETER
Material
Thickness.(inches)
6 FOUNDATION WALL
Material
Thickness (inches)
Brand Name Certainteed
Thermal Resistance (R -Value) R-13
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 Compliance, where applicable.
/27/00 PARAGON INSULATION
Item #s ignatu , Date U Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s
Signature, Date
Item #s Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
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