0012-267 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapi6 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
'71-41 / 3 1 . 40�33fZt
tiDate 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.
( Yr�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 0010 N KAOLE IM, Policy No
I
�l�riG 94406-��
(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 L should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, l shall forth'�with comply with those, provisions:)
Date: / ,h '/lit Applicant /Y _ A,—'
r
Warning: Failure to secureWorkers' 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. h is
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.-
Signature
urposes.'Sigature (Owner/Agent)� bate
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0012-267 TRACT
$:400,4.10 25 2956:
JOB SITE
APN
ADDRESS 45-910 XsAIFLOR LANX
4504-M-019
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MUMY' CLtOWE= I;!10MMWr'J_.13
MnIORY C ROWELL
1,535 30, !" ig' P-37, 5'rz 9.300
i 53:4 sx), ' yAmer. a`%" r, fizoo
SAW F"tc7AY-]f IX0 CA 92 409
SM BERNAia'1:11NO CA X408
(9b9 3i31 COni CX ;1 l 2.120
USE OF PERMIT
1:90141qNMr DV3LJiG
FI>. iii A.,3CR LOT 21. RRMTTI'YOES NUf INC.LU' fl
01AI ~KWAL'L&POOLIDA Ind'EWAY'APP44C. ACR73%; PLAN G''HECK FF:R ,
REDUCTION FOR ISSUANCE OFA&ME PI.A'N TYPE.
TRACT CO33S'YRUCT101,111 116"V.00 511'
PORC HIPATIO 94.00 ,019,
(}.r%1Rd3.MC.An+ IsOR (:) 8.l°�3.1E3
11✓�".C3At1917ED COST-flAr CORYI'1 U�.'l ION
AWA .10
PLAN C's3ECiti: FEE, i f�k-l9�0` �b3S�>:ndt14€� $133.55
' 71
M1PC1^I.WCAIsl'�, ��,«0i3[1647i1"O0i3 S'�3.5�
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i'� t;. � •,�
a' LIJIM[3iNC R19 101-000.4194)00 $128.75,
f *3
ST3"�(YN MOTION FiE - RESID 101-000-2,41-000 00.05
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(AADING MR $20.0
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UM �-FAXD WI'kQ
$0.00
YMWAVOUTM IE NOW
RECEIPT
DATE,i 't
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs Z CaQ..eK
Underground Ducts
Forms & Footings l$
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck S W1
Exhaust Fans
O.K. to Wrap 44('"�S
F.A.U.
Framing \Z
Compressor
Insulation _ $A�—
Vents
Fireplace P.L..
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
8Kp
BLOCKWALL A PROVALS
Final
POOLS - PAS
steel
Set Hacks
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 C *264
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection CSL
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)
INSULATION CERTIFICATE IC -1
45-910 LA FLOR LANE LA QUINTA
Number and Street City
Riverside 29563 25
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) R38
Loose Fill Type BLOWN IN Brand CERTAINTEED
Contractor's min installed weight square ft 0.615 14 3/4 inches
Manufacturer's installed weight per square foot to achieve Thermal Resistance (R -Value) R38
3 EXTERIOR WALL
Frame TVDe
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 Complianc , where applicable.
2, 3A 8/6/01 PARAGON INSULATION
Item #s S nature, D 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