0003-167 (SFD)I ; 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
71418b 6 IGJ311201
jr `'^• i r ��'
tDBte 1�.`',Signature of Contractor���/
OWNER -BUILDER DECLARATI,O/N _ +
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 & Prof essionals,Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( );t,6rn exempt under Section B&P.C. for this reason
Da _�p Signature of Owner. ;7A
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 proJided`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 is_sued.'My workers' compensation insurance carrier & policy.no. are:
Carrier Policy No.
0OLDEN EAGLE IN1S. N Wr_ 54 46U1
(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. .�
Date: •• Applicant Wit_?z r, ;/tt%^ it
Xr-77/a - . 4 .- 4 v ..
Why Ing. 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
the above-mentioned property for inspection purposes.
Vr nature (Owner/Agent) �!� t�L 1 E'�� f Date.
PERMIT #
,� e) BUILDING PERMIT 410.4611
ATE VALUATION $107?.547.80 L'OT S,L TRACT
JOB ADDRESS %4%. . t .��a�a� .! A
APN 604-M-009
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CF_:N' TMY C;ttaWEIL L 01MIRLUTIE8
CENTURY CROWEL , COMRo11.JNITI S
1535 SO. ",i)" S'MIEFT, SfE. X1200
1535 SO. "D' STREZ.1, SM #200
SANT .BER.)VA.RVN'O CA. 92408
SAID .l3I:'RN1A.1dDINI O C;A. 92408
(909)381-6007 CI?1 n 2!70
USE OF PERMIT
S NGLE FAMILY DWELLING
SM- :LOT 32 PLAN 5ODS NOT INC]LUDr, BLOCK WALLS OR .POOL
TRAC 1' CONSTRUCTION,. 1,718.W, SF
PeiRC:rUPATiCS 48.00 SF
GAf2AWYCARPOR.T 695.00 SF
1.H'�"�'ii>i AT D C€ ST O i:L1'NS Ta�idC° IONT
107,5#r"� Q
PERMIT EW Sa1:1Mi1 AKA
CONSTRUCTION FEF 101-000418.000 5667,50
M,ANCIfT:CKFRE 101-ilM-439-318 E351.P11
IMECHANtCAL FEM 101-000-421-000 $47.00
r
£,LHO,iRiCAr FLS 101-000-420-000 $122.53
PF,t!i il`tt} f'1?E 101-M)-419-000 $128.75
5`rRONG tL OTYON ;t EF - RX, SIP 101, -OW -211.000 I;z.tl.75
0 RAD IN a 417 la: 101 -000423 -ON)
ART IN PUBLIC KA1C.ES -1-ES11 701-000-255-000 520.00
'.� �•' � "
StJ t'0't A.L. CON1SML1C"-"? 1.0N AND 1"T.AN CHECK
$3,475.36
LESS PR-PAL'.?.FEES
$0.00
'I'C}°6'AJ, IPERA'd; T iC+ KIMS D IF, NOW
S3,475.36
RECEIPT
DATE
BY/ ' f'
DATF FI„NAL€P
IN$PEGTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
- t -Qb
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
I 7Z -
F.A.U.
Framing
26
Compressor
Insulation
15
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
I I
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 Laterals
p
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
�o
Appliances
Final
Final v
Utility Notice (Gas) e
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 `o Lco
Utility Notice (Perm)
COMMENTS:
W�
INSULATION CERTIFICATE IC -1
79-320 Sierra Vista La Quinta
Number and Street City
Riverside 27519 32
County Tract No Lot Number
Description of Installation
1 ROOF
Material
Thickness (inches)
Brand Name
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 ignat , Date 0 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