0012-257 (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
Date f� Signature of Contractor -
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).
O 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. '
( 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.
(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 f6rjh6th comply with those'provisions.
Date:
te:/.;% ']S�/f- Applicant—r7' l.:
�-'#`" 'rte ✓ ,N � . �y �'-'^ _
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.
griature (Owner/Agent) "al ��-`'�1 ✓ Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 00124—S? TRACT
&x:1.?, Q4100-2,2 .29143
JOB SITE
APN
ADDRESS
45-945 ,LA .Ei•'1i3OT LAM.
604-00-039
OWNER
CONTRACTOR / DESIGNER / ENGINEER
r_ 'Ni`1:7!,RY CROWELL (2101+&A"Cwnl
Ck`Mity' C.hSOWE'u., C0WV1UN T1'11*,.9
1535 no. ;D. s.x f: , tru'..0200
153530, T" VfRT ', 9M,0200
9,AY+i F,3EWAEtI7WO C"A. 92408
3.t R .1l3RR ''AP: 1X0 CA 92408
- (909)381.6!x(4"1 C� 2120
USE OF PERMIT
SINGLE FAMRIV, M=M
Wn.). PiANsAfrT::23 .MMIT DS1407raCLUDE
BLOCppA1,11POODRA WA KPMAwI$6VPLTq CREEK EMI?-
RBOUCTIOH FOR 1SSl7A3+9fr:t; OPSAME PLKN `HYPE:
'311AC;T CONSTRUCTION 2009.00 OF
OORC;H1Pt1,TIO 48.00 Ski
0ARAUFMAl1PORT (9. 1) 8,1'7'3„,0'
WI'11 AT..F-D COff OF Ct3N�'['RLYC"°:�`�ON
AMM -00
PIS FEE UUMMMY
!CONS1'1ttiGi`IUR FER 101-tlOD'419.001 S 02A
PLAN CHWKFR1a 5C1-f1Q13��i39-;3its l�36.�3
i ,,=- -a
MECHANIC .A1. ME 101.4000.421.001
73:,EJ,L"7Rlz.+lR.f , FEE 0420*obo
t
r{
;�**�,++'' qq��,rr��ry�g y�pppp ��ry l i31 `Ii0*,419-00C
6"�Vli!t�l 40 ;'7M .
STRONiMOTIONFEE RF SID 101-000-241-000 Sum,
ryzM110 101.000-423MQ $20100
t7OTLLMER, IMPACT .FEM
33l -TiMAL(7243 RTIC"'1"Tt7MAND PLAM CIM7,...
$3,099.69
MOB PRE -PAD F870
$0,00
IMAL PMOMYEEN DUN NOW
00"168
RECEIPT
DATE ( %%
��►i;y
BY
���•,�.
DATE FINALED
INSPECTOR
fav
l r.�. _-
A
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
2A
( 'L-
Ducts
Slab Grade
Return Air
Steel
gj 1-5,-
Combustion Air
Roof Deck
—7
�C—L
Exhaust Fans
O.K. to Wrap
Framing
���g
F.A.U.
Compressor
Insulation
Fireplace P.L.
��
��
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�j
Final ` , z ,�/
BLOCKWALL APPROVALS
Final
•
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
--7—
-3F��
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
Final
Utility Notice (Perm) (O'
U
INSULATION CERTIFICATE
45-925 LA FLOR LANE
LA QUINTA
City
IC -1
Riverside 29563 23
County Tract No Lot Number
Description of Installation
1 ROOF
Material
Thickness (inches)
2 CEILING
Brand Name
Termal Resistance (R -Value)
Batt or Blanket Type BATT Brand Name CERTAINTEED
Thickness (inches) 12 Thermal Resistance (R -Value) R38
Loose Fill Type BLOWN IN Brand CERTAINTEED
Contractors min installed weight square ft 0.615 14 3/4 inches
Manufacturers installed weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR WALL
Frame Tvoe
A. Cavity Insulation
Material BATT
Thickness (inches) 31/2
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) R13
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.
2, 3A 8/6/01 PARAGON INSULATION
Item #s S' a ure, DA a 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