0012-266 (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
"Pofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
71 4I RS D 1013'1/2(
fate7!�;' AL. .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).
() 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 OOLDEN EA01A D4.91 . Policy No. NWC•344069r02
(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,
1 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 shahforthwith comply with those provisions. f - •
Date: r _,', �t,''o-o'�Applicant -'"fir) I X/61 t < F.Ae_M(j
�_ JV.
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.'
Signature (Owner/Agent) ) 7-f i /'fes , Date ZL__r�i
BUILDING PERMIT PERMIT#
DATE, VALUATION LOT W)J•Z-2"1 TRACT
24 2� 63
JOB SITE
ADDRESS
APN
1
4-3-W MAIFLOR LANK
6044)61.4)19
OWNER
CONTRACTOR / DESIGNER / ENGINEER
GWTURY ('i OWMIL Comfduk'Inn
CDMRY CROWEU COMMU 7F,I'M
1535 so. T. UnRuT, =,11200
1535 SO, *D* STREXr, ME P200
43AN BEMAMNO CA 92408
SAN I:+ERNARDINO CA 92408
(909),381.6007. ("But 2120
USE OF PERMIT
7OT .P, FAMMY DWMATAIING
`irr'. P1.;kN;n1P, F,O'T' x Puma w:Cis N, -r mCIl ualy.
8!.,t'1t':KWAi..ASW0UDft1vMAY IAV PP.(>410I(,' 1% P Y.M Cfive K R10
I'fEDUC'4 IM POR ISSL AN► C g OF SA}?A X PLAN TYPE.
'Fti.,ACT COV1 TR.U1CTION 1,679,40 sp
POR.-CHI'PA,I'IO S4.00 SP
GARAMfC1 RPORT (S�) x,113,20
;1 SJ.IIn+tA,':r`' COST 011} COMM'UO'I70N
1000 :l 10
1 iffiwrVIT, S['SfltR;t't+1:ARY
CONSTRUCTIONMY 10),,000.418.WO
PLA14 CI• VZK: FEE 101-000-439-•318
WCHANIC L Me 101.0001421-000 953.54
BLECTRlCAllF89 101-000420_000 $100•61
PLUf;i�k two 101.000.419-000 S128.7s
- C 3
S'fii:,Oi�ICF R4f�'I`IO1,F P"f'��. � RP211D lot- 00-`2�1I-000 $10.05
-,L
''
ORADI O E'ER 101-WO„423*000- sz,0,00
( J
Dr,vubI"E'SQ.IidlP.t cT Tin. �3,9sYi.CifJ
14� I�� C.J
SM. `IOTA CC►NMR=F+L"!W AND T>I" CIRC.
$2,5196.46
I.X33 PA. i. �
1 $0.007
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS .
Set Backs
7-1$ d.)42 -AA
Underground Ducts
Forms & Footings
CoMpe
Ducts
Slab Grade
'�
Return Air
Steel-�.S
Roof Deck
O.K. to Wrap
_ (Z� C c�
Combustion Air
Exhaust Fans
F.A.U.
Framing
c� 12�t.o
Compressor
Insulation
Fireplace P.L.
S �.Z
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
s ��
Drywall - Int. Lath
Finaljo/ 6�
BLOCKWAPPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
rground Plbg. Test
Final
iping
PLUMBING APPROVAest
ic Final
Waste Lines
2�$r
Final
Water Piping
qGa
ing Final
Plumbing Top Out
ment Enclosure .
Shower Pans
for Finish Plaster
Sewer Lateral
\?�
over
Sewer Connection
2'3
psulation
Gas Piping
Gas Test
Appliances
Final
Final l
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) ���
COMMENTS:
TION CERTIFICATE
45-905 LA FLOR LANE
14 -umber an
Riverside
LA QUINTA
City
29563 24
IC -1
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
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 Type
A. Cavity Insulation
- Material BATT
Thickness (inches) - 31/2
B. Exterior Foam Sheathing
Material
Thickness (inches)
4 FLOOR OVER GARAGE AREA
Material
Thickness (inches)
f 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 Compliancwhere applicable.
N
e
2, 3A 8/6/01 PARAGON INSULATION
Item is nature, ate Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s Signature, Date
Item #s - , Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner