0107-163 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 5 (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
_711 �
Date �' }a %: 7 Signature of Contractor sy ` '' / 7 �" A T
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). r
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct 4the 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.
(#t71. EN KAO LE MS. r titR: l�8td�-0Z.
(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'/p f
1. ✓ - r
Date: r r> 41,� Applicant 1' J'I
s ✓ t.• r �l r _.
Warning. Failure to secure Workers' Compensation coverage is unlawful and
shall subject ari-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 representativesof !this City to enter upon,
the above-mentioned property for inspection purposes`'. /
1+'S
~� P r: i F lay
ignature (Owner/Agent)�a�' --: � �<r.,�-rlF � � Date
w[r ,7 7r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (}�,� �� TRACT
22 239.95-T
JOB SITE
ADDRESS
APN
+Ii&S7�L�t��0
OWNER
CONTRACTOR/ DESIGNER/ EN INEER
153.5 001 11V RiwL x:171.42.00
1535 30, T4 a1IKEEK4 STT, 0,00
0
(,900)3B1,.6w.P CB1101 2120
USE OF PERMIT
31044T 22S PLAN M& PERMIT WM. ' NOT INCLUDE MOCK W.,-J�L t7.s4'
THIS 13 THE BUILD OUT MO.M THE PAIMHO HO L,OT
TRACT MISTh'.UCTION 4,900.t10 aF
4aOMC.W;<•'ATIO 37.00 sp
0A MMMM 420.00 aF
Elall n"rm COM, Orr CONS,M(MOA'i
106,397.60
CCI-I;TRUCTION FE -9 11014=418-11M 1664,00
PIAN CHECK A'ME 1W-0004", -318 $550aso
MECi•IANICAL .n -X 101.000.421-M)
E'.XV111Pt.tC AL. I; RIa *10'1-000-420-000 81 t x.90;
PI,1,1M11:PdO FEE 101.000.419.000 1137,231:n,
S f`aONG %atlf rICIIN MR - RESID 101-�`Jf3(1�` . 1-000 $1044-1 ,
l�► l7T?k l lui 101. -423.000Jr3r' �-
DEVELOPER, T7Nl P T ice: t'f
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jtoot s Jnr {
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ID
TOTAL rrx ` ml Y•."lL rY YTE 140w, i
- 93,4%.59
RECEIPT
DATE t'
BY [J!,
DA LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
/
Ducts
Return Air
Steel
Roof Deck
r _
f
Combustion Air
Exhaust Fans
O.K. to Wrap,
_ _ _
I_
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
1Q-1?
Drywall - Int. Lath
Final
Final
�3B -o/t ,
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
/��2 6 _ 51/
PLUMBING APPROVALS
Gas Test
df
Electric Final
Waste Lines
�/ / L
Heater Final11
Water Piping`-�
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
��'
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
�� .3L�✓
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
Final
Utility Notice (Perm).
���
11/29/2001 T)HU 19:25 FAX
12002
INSULATION CERTIFICATE IC®1
LA QUINTA
r-45=575 SUNSR06k LANE City
Number and Street
«.. 22
Riverside ------Loo Number
® CountyTract No
Description of Installation
1 ROOF
Material
Thickness (inches)
CEILING
Batt or Blanket Tye BATT _
Thickness Caches) 10
Loose Fill T
Contractor's min installed weight square it
Manufacturer's installed weight per square foot to achieve
EXTERIOR WALL
Frame Tyoe -
A. Cavityinsulation
Material BATT
Thickness (inches) 3112
B. Exterior Foam Sheathing
Material
Thickness (inches)
—
4 FLOOR OVER GARAGE. AREA
Material
Thickness (inches)
5 SLAB FLOOR/PERIMETER
Material
Thickness (inches) --_
Brand Name
Termai Resistance R Value
Brand Name CERTAINTEED
Thermal Resistance (R -Value) : R30
Brand
inches
Thermal Resistance (R -Value)
Brand Name CERTAINTEED
Thermal Resistance (R -Value} Rt3 _
Brand Name
Thermal Resistance (R -Value)
Brand Name' _
Thermal Resistance (R -Value) --
rand Name
Thermal Resistance(R-Value)
-77
6 FOUNDATION WALL Brand Name
Material
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
Bnergy el&rciency Standards for residential buildings (Ttle 24, part 6, Cal'cfronia Code of Regulations) as Indicated on the
Certificate of Compliant, wh re applicable.
2,3 111?9f01
Item #S (Si nature, Dide
.Item #s Signature, Date
Item #s Signature, Date
PARAGON INSULATION
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Go. Name) OR
General Contract (Co. Name) OR Owner