0003-181 (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,
x.141 RM
& � 31 il0f
Date aJJ
1(`*p� "�}%j 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 isnot intended or offered for
sale (Sec. 7044, Business & Professionals Code). '
( ) I; as owner of the property, am exclusively contracting with licensed
contractors to 'constr6ct '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 ,C)LU.UfV EAC,;.; 1t�; ;, Policy No. ti�1dC 544w_
fJ
(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,provisiona
Date: !1�t Applicant �!� s.o F
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under.or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. J agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above mentioned property for inspection purposes.
Signature (Owner/Agent)
m,n
PERMI�a�&�
BUILDING@
rPERMIT
-DATE VALUATION.5+�4:�o•2b%•lDV L�.OT-!/ra TRACT -
7
JOB SITECt: i4l' 1EF.1U k ;UYV7
APN 604-06.1 E� 9
ADDRESS
OWNER
DE. DESIGNER/
. *CONTRACTOR/
121111'rullY1}•�1Y3E11Y.• ri10y AKPTI2IS
i, 4R10011111,11.1.1, 's
CJYpU.11ME
1533 SO. "I7" STREET, S'A'E. 10"00
t 533 SO. "i3" STR. , Or, §;f E. #2U0
SA.N ,13E NAROINO CA 924015
S.AN .13ERNA:RDMO Cel 92408
(909)381-6007 C:'611# 2120
USE OF PERMIT
SI-NOLE PAMfLY 1~►WE LUNG
.bilLd_ :Uj 1 +(:R el.OU4 ') alutl (1t1 t f: ut"N (14V 1 1.114t;E J,1$LUk.,A.WALL UK
1100L. 750A PLAN CiikiM F Elii Rt 1AJC J 100 ON MU -11 1PLB 1SSilMr. E OF
SAMEPLAN 1.YPE.
TRACT C0!43rRUl r1,GiN �I. 7 18.GG s
p0RCIVII AT IG 48.00 SF
E' s INN TIED COST OF C011"d sTRUM,ION
107,M .30
� c�FAMI FEZ U..MMARY
r a
CONS"I LTC TION FEE 10.1-000-4111.000 $667,54)
Pr,atvt'Fi?.C1 FpF. 101.40-439-318 $137.96
-'
ILiI Cu"MCAL F"M 101-000-421-000 547.43
:.
:'1:1r'CT1tILt1L ME ;t1-1�t}€i-420-€lOG �E?x.53
a
PLUMB(NGFEE, $128.75
+'I`RONf.* TV10'E' 0, N F'Mi. - RTiyfD 101 -tom -241-11011 V015
GILIWING FES 101, -WO -423-000 MOO
� i'1
=
DLiMOEER IWAC l :FEE $1,907.00
i'
ART fN PUBLIC PLACES R,8SFC 70.1-000-25-11-M
St f ':1 37 nab. CANS' R� CT01� A1u`1�'PT,.ar� C.fiECK.
53.061.49
LESS PRE -PAID PEPS
$0,00
TCAAL P.".i1iR.IV/.P.T .F M 0V NOW
$3,061.49
RECEIPT
DATE
8� / /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
m. -40
Underground Ducts
Forms & Footings
55Ducts
Slab Grade
5,-10_e6
Return Air
Steel—
..
Combustion Air
Roof Deck
(, • .Z
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Insulation
L4
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
J`r oD
Drywall - Int. Lath
Ell 14 1,00
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
Lt -00
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
j. _Ij
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final ca
Utility Notice (Gas) o
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)
COMMENTS:
,
INSULATION CERTIFICATE IC -1
79-351 Sierra Vista La Quinta
Number and Street City
Riverside 27519 49
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 Type "
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)
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)
6 FOUNDATION WALL
Material Brand Name
Thickness (inches) 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 Complianc ,where applicable.
bjl 127/00 PARAGON INSULATION
Item #s ignatur Date 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