0003-142 (SFD)- LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 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 W B 10+'3110(
Date - � Signature of Contractor i 46L 6- Y
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 I, 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'..conipensation 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 * �� p� /.r { Policy No. •�, 77�//w'. Q,11 ,�p
CsO1.U`.L`N Y NIM 11JS. I4)WI 1544068.0.1 '
(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.
APPlicant" tICLJ±��-l9-�f:1a
v -
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
the above-mentioned property for inspection purposes.
4,/�G'IL.(. A-�1; Date -2-'1 , )
Signature (Owner/Agent) ': _
�1
BUILDING PERMIT PERMIT���Z
LATE VALUATION M.00.460.10 S_01=3= TRACT
JOB SITE
ADDRESS t•Ti 9 Illi �1I1� � .CA .
APN 604-061-009
OWNER
CONTRACTOR / DESIGNER / ENGINEER
rli,'ji'rr�r!?jr,-p -%V LY ,,f T& 'r'jEs
VAI. I4' WIr+ lY'llll !4-.A
(:ET'vI�.;n'V I"IT./�1N\ ETI CO-"'I�tl"NT"FES
1 1 .\•-1 4.i\ YLi1aLI 1 aFVAY.!1�.1.1.4.1y L:1
1535 SO. 4D" STREM, STE. #200
SA1QT :B.ERNARMNO CA 92409
SAN B RNAhDINO CA 92 O8
(909)381-6007 C131.4 2120
USE OF PERMIT
SIMYLI B :h"A.MILL 1' DWELLING
yam.. LOT 31 PLAN 3 DOES NOT M Lt,.UDE T3L.4 JCti WALLS OR FOOL
;.rZAC'TCONSIMUCTIGN 1,6;9.00 Sr
PC'i1tC.6VI ATiO 84.00 SF
GAXA0E1CAR 0,.E r 417,60 Sr•
rLI S lMl.f.4.t,TJC./J CM f Va, COINwyTSab>MIX)AT
vx), 60.10
yy 3�ryyp� gg ''��t��ggee �ryg� �,y ,(
b�ERIT11IF 7'.i:E laJ��tV4i' R '
CONSTR.k)(3110N FIE13 101-i}0041.5-000 $643.00
:nt..A4C13F4 .F?F 1014"-439-:318
XV--t_TAXICA.L.t`LE 1.01-000-112.1-000 $53.50
ELL, CTRIC AL FE E 101,000-420-000 $415,61
FIL,UAtii: ING F%E 101-000.4.10-000 $128.75
L4'f13O:sVG MOTION l:I-7a.10-000-2414)00 .�?O.OS
`'•� c �,.;�
CIZA0;1NIG X103 .101-000-423-000 $20.01.
'DEVELOPER OPER FAIPACT MT $1,907.01)
1:11, r�'
Aff 1N PUBLIC :PLAC;I .S - R931k: 701-000-255.000 $20.041
Ir`t 14• -
r
SUB -TO, TA1, CC)NSTR(.fC 1`10N A -N1 PLAN C: H ,C.ir'
$3.43-2.1?
LESS PRE—PA1j) FEES
50.00
"LIMA1:.PERMIT 1 U1. DUE NOW
0,432.12
n6£c r T
DATE
?v, / 1
ATE SINAI En
INSPFnTr1R '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
'g— l -M
Combustion Air
Roof Deck
[ _
Exhaust Fans
O.K. to Wrap
_
F.A.U.
Framing
Compressor
Insulation
8 vi C9
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
(p
Drywall - Int. Lath
( 02
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
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 Z.
Final
Utility Notice (Perm)
INSULATION CERTIFICATE IC -1
79-310 Sierra Vista La Quinta
Number and Street City
Riverside 27519 31
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
tBrand'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
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 for residential buildings (Title 24, part 6,
Califronia Code of Regulations) as indicated on the
Certificate of Compliance, where applicable.
/27/00
PARAGON INSULATION
Item #s ignatiYe, Date 0
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
0