0003-172 (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
71418$ 1`S 1013//20
i
ate- , Signature of Contractor �✓' )
OWN ER -B UILDER.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 - Policy No. . `
G(„ LLM..fti .rtL�11 Ir1S.. a'�1Td 5140b3-01.
(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: - \:
4w`arriing:
ApplicantyFailure 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 comperisation, 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
Mee�'abuve-inui lured prupeliy rrul InsNeeutiuli puipusus.
f
iSign`ature (Owner/Agent) r� iI It/`1a.�/�s/ Date �;7/�-_�
PERM140#,1�3i72
." '`-' BUILDING
pPERpMIT `�
DATE VALUATION S".161L.80 LOT ( TRACT ,
JOB SITE 1 - ' '�
APN "4-061-009 .
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
!•�TAirilf Ti�jJtl�NrGC t1t��AbUTAr1r'rC:C'
4A^.iV A: VI,. \V kb l: Ra ,.6.4 A\4 zve .4 L�.:4S
�•rnrrtntv�'an��rr;f f T, 'T
\i i:.,lV fib�l.R..A 1rr %UO bb b/..l.. a..4Jf. EJY/l. )I6.14{r�i
SO. RLQ" STR F MT. #200
1.535 SO. "W $'1 MEET, SFE. 0200
,
SAN til WARDINO (-:.A, 92408
SAN B'ER AR:i: ITNO Ltd 92408
0)0913,81-6007 CRL# 2.420
USE OF PERMIT
��77}}� �r �+y�, s 7 n7
INOLE PA.NUL R D W ).'.LEAN.
ST, D- LOi a f PLAN'2 PEWIT DOES NOT .1T'sC:1X ETS1.tJl.;P:WALL OR
V00L. 751,-b PLAN 0-11133f,K f0H RFDUC T10N (YN MULTIPI E ISSUANCE OF
SAW.- PLAN'n-PE.
TILUIC, 8TRU-C ICN 1,500.00 V
€ O RC PATIO 3o.0fl St'
VARAl'tl CAItX)kY 420.00 SF
l
E'ST11�,3AT ED COST OF CONSTRUCTION
'�, t60aii41
PEM-Niff-f FER SUMMARY
C QNS"fRUCfK N FEE 10:1-000-41"00
PI -1 N CKOK r '
&I.-01IAN-1CA L r,E.E 101-b00-(521.000 $4 7_001
. .
O ECT..FcT(;Al.:[ R M--WO-420-300
PLUTNIBI'NG FHE 101-000-1.19-000 - $122.75
�c1'K{it'C4 ^de rfi4�?d _ _ ItF.Sii� i(iR-Qi()-24.l-Q(1(j $9.02
p "i
GIZIA 111110+ FEKE 101-000-423-000 $.70.00
r �
1)LsY1; LOP%(. tTATOACT Fax ;BI'm.00
St_Ir$= C(3Tq►: COw$ rfz r�c�~riON N �T., �[ t' -K
52,938.69
LESS _t'RI:-ITWD IFEES
$0.00
T t`9',11 AL ]JFJKlY11*.8. DUEL O
bD.la`�7ae14.6p
RECEIPT
DATEBy
r
DATE FINALED
INSPECTOR
71Y
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
S` -
Return Air
Steel
S_
Combustion Air
Roof Deck
o
Exhaust Fans
O.K. to Wrap
7_ (j -.C�pz
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
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_ -L. . 00
Heater Final
Water Piping
Plumbing Final.
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
. (4743D
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
3�
Appliances
Final
Final
Utility Notice (Gas) (21 Lo
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 p �o
Utility Notice (Perm)
COMMENTS:
INSULATION CERTIFICATE IC -1
79-370 Sierra Vista La Quinta
Number and Street City
Riverside 27519 37
County Tract No Lot Number
Description of Installation
1 ROOF
b
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.
9/27/00 PARAGON INSULATION
Item #s ignatu , Date 9 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