0003-174 (SFD)LICENSED CONTRACTOR DECLARATION
I helieby 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
71419-9 B 10 3111CA
�j1
Date Signature of Contractor rt ) - f\ .I1 -f ( .S
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:
Carrier GOL;�LsN GA.CI,Cs INS, Policy No. AWC "4065-01
(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..1 J
Date:�- 14 Applicant
'I, 4L/ if
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, indemnity
& 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-mentioned property for inspection purpesc3. /111
Signature (Owner/Agent) 1�1� 1,) ! Ir� Date
p •.`, j.:!l111 z5
BUILDING PERMIT PERMIT4H)03-174
DATE VALUATION S16I,W-10 LOT -341, TRACT
l
JOB SITE J79-390 SIV VISTA
APN 1604-M-009
ADDRESS
OWNER
CONTRACTOR / DESIGNER I ENGINEER
CF.NiLT,` C } fiL* COX{MIUR ES
CENn MY LsNr1",1. .J✓i IE
1535 SO. "D" KIRFET, ME. 9200
1535 SO. "D" S" `R ET, m,. #200
SAN IS.EPWARDINO CA 92408
SAN HERNAMNO CA 92405
(909)381-6007 C'81,0 7120
USE OF PERMIT
"INGLE FAMILY EAVELLING
9FO-LOT 39 PLAN 3 DO&S NOT IN43 u.UE BLO(KWALL O1`c POOL:
'756/4 ,PLAN CHECK FEE it!AAJCTIUN ON M R,'!'LKX ISSUANC h UN SAME
PLAN TY'Ki.
TRACT C ON'STRUCTICrN 1.679A0 3r
Pt:tcMPAX10 84.00 S.t'
<3AKM,;WCA iLP(.)R1' 417.00 S1
):a'+7•l,i14'llCf i.11IMMS i OF CO NS S i�I i.+Ti.. B ONT
1.0.460.10
i�T+;RIMIT FEE SUMMARYE
(.'ONVXVC TIUN 11' i 1.01-001.1-41.8-000 S641W
PFF ittl,-11Ot}_a9�31K 513 5�
RMCIIANICAL VU? :OI-'.l'J'v' -'ei1-000
:ELEC:TRICAL FU 101-0000-420-000
PLUAdHNOFFE 101-000419433) 5128.75
117
f;'1'ttONO RdoTTc"rrf rmi-12Pstn 1!!! 4)11(1-241-0010 %133 0S
ORA17rN.10 YET. 101-000-423-000
i.7isV1`LOPEdZ.Ii`1►.3k'Ak,'TPIs1: 51,90 7.00
AId.'.0 IN iPU19f. C PLA.CliS - RE81 ; 70I -OW -255 -OW
tr
SUR- 111.A1. c:C3N,VTR1.TCM0N ANT) PIJAN 041ir. #C
$-A Ii31 461
LESS PREA'..'LID FEES
$0.00
'i MA. L 1.'KitlNIX F-KIOS DUE NOW
$3.031.46
RECEIPT
DATE 14Y ��
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
S - r o d
Return Air
Steel
Isalp
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
- (i 4
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
814
Drywall - Int. Lath
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
("L . t10
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
q _ 00
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) k o%\I pp
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 I a kr, C9
Utility Notice (Perm)
COMMENTS:
INSULATION CERTIFICATE
IC-1
79-390 Sierra Vista
La Quinta
Number and Street
City
Riverside
27519 • 39
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
Brand Name Certainteed
Thickness (inches) 3.5
Thermal Resistance (R-Value) R-13
B. Exterior Foam Sheathing
Material '
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
j
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 fo .residential buildings (Title 24; part 6, Califronia Code of Regulations) as indicated on the
Certificate of Compliance, where applicable.
\,O /n m' A e✓9/27/00
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