0003-176 (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
7141813 13 ilii3l: 2G+
,t
Dated E i %� � Signature of Contractor `�7 „:� +���%A
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that,l 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).
( ) 1, 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 liy 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 GOLDEN EAM;; WS. Policy No. NWC 5:14068-01.
(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. �s
Dater r�.t , 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
thu abuve-nienlluned Niupulty fui Iiibpeullun Nuipuses.
Signature (Owner/Agent)- )'t L�L4z & l Date -'
PERMIT#
.�u ' BUILDING PERMIT Qh913.3-9 7G
u
L�pT yl TRACT
�AZE VALUATION TRACT
JOB SITE 1,10-VIRRI . i�, STA
APN 604-061-00
ADDRESS
OWNER
CONTRACTOR /DESIGNER /ENGINEER
CENTURY CkOa L .OM-ILJiTC`
caffuRy 4OATLL /rLI�'ris
1535 SO. T" 91-REET, STE. ##200
1535 5O. ` W S"TREE'1', Mi. ##200
SAN $EMA:N.C)1_'Nra CA 92408
SANBERNA:R IXINO CA 92408
(409)V. 1-6007 CB!,.#i' 21.20
USE OF PERMIT
S1N+. LEFAMILY';i WELLIN�,e
%;D -LOT +1 PLAN 3 PERART D( NOT INCLUDE BLOCKWALL OR PV OL. .
't5° o ))I,A14 CHECK FFE REDUCTION ON MULTIPLE ISSUANCE OF SAME
PLM.4 :f'YPF.
TRACT' CONT.STRUC ION 1.679.00 5F,
PORCHiPACIO 84.00 SF
t;- A*( L0k;iCA1W,01Cf 417,00 SF
TIMATEID i;M OR+ CONSTRUCTION1
1001460.10
PEilEAUT FEE SUMMARY
CIONSt'iCi 1JC'C.tU')r rEE 101-000-418-000 W3.00
P1,.1>sAl C-14f3rX ' EY, 101-f}(1f, 09-31 K
N4C-Ck ANICA,i. M3 101 _000,42 1 QiO $53.50
.
ELECTRICAL FER i 0.1 -OW -420-G00 3115.61
I'1-thWA:i`fc:IFEE 101 -OW -419-M)
z' �
ti'1`fdt7jtOtylei'f'TONFFF RESTO I01-(�jfyIO-?d1,-fjl?0 �1,t7fi5
•�. ; y
+Si{!`wTii J l!l.:ii 1.01-�+ - O-42.3-0 0 6 13.�jf}
`_� ! -• �+,.
••+ yi ;
DEVE QYIEIt RNP1kcr 1"IiL $1,907.00
AItl' 4N PUBLIC KACHS - RE'StU 701-000-` 55-(300LJ
81.ti :RDTAT C' ONS-l.'RUCT10114 AND MAN CRECK
51,011.46
LESS PRETAID ILLS
$0.00
RECEIPT
DATE
BY =/'DATEA
FINALED
INSPECTOR
�
"a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
•do XP
Ducts
Slab Grade
. c?_ 6p 14
Return Air
Steel
- -j .W
Combustion Air
Roof Deck
f . sQ
Exhaust Fans
O.K. to Wrap
1 -06
F.A.U.
Framing
T-
Compressor
Insulation
S —AliVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
S• Z.-m(�
Drywall - Int. Lath
jg•
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
• I
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
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
Final2� �da
Utility Notice (Perm) .'Ll -co
INSULATION CERTIFICATE IC -1
79-410 Sierra Vista La Quinta
Number and Street City
Riverside 27519 41
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 TVDe
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-Valuej
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.
,&zr_ .� 9/27/00 PARAGON INSULATION
Item #s Signatur , Date Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s
Item #s
Signature, Date
Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner