0003-177 (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;
. 7141n B I i0i- 1100
Date 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
Ihereby affirm under penalty of perjury one, of the following declarations:
() I have and will'mairitain 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 Cf ,.DEIN E4k(;LR 11NS.. Policy No. N`,VC 544068L01
(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, arid 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.0 l./ %'
Date:• �, _ �� t/ v Applicant Ef'`r d C C -t �'1 %'
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
thu abuve-menlluned plupelly ful Inspeullun PUIPuses.
Signature (Owner/Agent)7f�\ ° 0}3 L(_ � (_r111% Date
no
PERMITf��4
BUILDING
�PERMIToT`
TRVALUATION ACT
tAT� RACT
JOB SITE M739,'a� 4.�1g�
APN
ADDRESS
OWNER
CONTRACTOR /DESIGNER /ENGINEER
Cf -'.N f�pp !ririnni1:C:INIMP�a,
CXM1pY
Or, 1130. rD" ST MH7r, STE19200
;.AN Ea1:RNAtt:1,)LNO CA 92408
SAN RMNARDUNO CA 1,4.2408
(9N1391-6007 C RIX 2120
USE OF PERMIT
S ivvLE EAIMILY 13W'ELLfWj
ut•1J !,� 4 4a 1rLH1'rt E .t" %UVli l i-MitS CVC:'.E 1Nk-ri .uJJL 136v,t ;K WALL Vic l"ut-0... .
'1,51/10:PLAN i;l.It.:l: K Me f21:aJtic '! ION ON A4UL.'1,tPLE LS:siJ.F1'NQki OF SAAQ�
TARMC,T 031 .SMI'.LTU1101i 11.5W.00 air
l+ iR 1-U4'A:10 .36.00 S
UAKAUWARPOR1 420.Ci+.t SF
11111IR V iT FEE NU.MAIAR
C'ONS`C.RVC'i'tOIvFEF 101-000--418-O ffi SSv�J.t�U
Pj., AN ('.S,FEE 1 Q 1-i1()fj-439-M g 3 24.52
as�^nxy ns.�y r^rn % r 1h1 /V� Ar14 F�htt A r
lV.it:A.11fit tl lSft2# . Y� d:i
\
uwx
LiXC17th~: r L 1E;% .1101 -OM 420-000 $109.40
- .S
PILE tt<4F3:INC4 ME 1601-000-419-000 $122.'73
= `'
�31�1C=1v1't"aT(ON 1171 - RESID 101-01M-:241-W.�y o3
5
GRAO1L'�G FIRE 101-000.42.3--00
fafsl; l.i �T1!`siG :c PAS: T ! Ec �.4,lt)'J n;►
1
St d "fA 1., CnN4M; {C? ON AND KAN CHECK
r � l�oc n�"DFr
H nlw 1 lA1f-Y ;C t Y+r.4Fr
tib,
WL'.A.L, i'R.6iM.IT L+"8PON DUE NOW
$1.938.60
RECEIPT
DATE
tBY'
DATE FINALED
INSPECTOR
V
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
5—1 0—
Return Air
Steel
5 -i
Combustion Air
Roof Deck
, Z _
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
e•
Final
BLOCKWALL APPROVALS
Final
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
.'? d
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
. [ S
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
oc7
Appliances
Final
Final
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 b
Utility Notice (Perm) '�j
COMMENTS:
C�
INSULATION CERTIFICATE
• �• IC.1
79-391 Sierra Vista
La Quinta
Number and Street
City
Riverside
' 27519 45
County
Tract No Lot Number
Description of Installation
PROOF
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
Brand Name Certainteed
Thickness (inches) • 3.5
Thermal Resistance (R-Value) R-13
B. Exterior Foam Sheathing
Materiair
Brand Name
Thickness (inches)
Thermal Resistance (R-Value)
4 FLOOR OVER: GARAGE AREA
Material
Brand Name ;
Thickness (inches)
Thermal Resistance (R-Value)
5 SLAB FLOOR/PERIMETER
Material
Brand Name
Thickness (inches)
Thermal Resistance (R-Value)
6 FOUNDATION WALL
Material
Brand Name
Thickness (inches)
Thermal Resistance (R-Valde)
Declaration
I hereby certify that the above insulation was installed in the building and the above location in conformance with the current
Energy Efficiency Sfanderds for residential buildings (Title 24; part 6, Califronia Code of Regulations) as indicated ori the
Certificate of Compliance, where applicable.
9/27/00
PARAGON INSULATION
Item #s ignatur, , Date
Installing Subcontractor (Co. Name) OR
.
General Contract (Co. Name) OR Owner
Item #s Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, Date •
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
C�