0012-273 (SFD)LICENSED CONTRACTOR DECLARATION
!,hereby affirm under penalty of perjury that I am licensed under provisions of
`i.°Ftapter 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
i
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 Policy No.
at't7.Ixv1 wwl;rr f23a. 3 £"• A6 >C!2
(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,] shall forthwith comply with those provisions. r dr
Date: r ' V11 Applicant i
'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
wh6se 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. a
f r' �'
Signature (Owner/Agentj- WO, XLO� : �-• �' ;? A Date � �.�
BUILDING PERMIT PERMIT Y
DATE VALUATION LOT '��`6;"�
TRACT
7
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JOB SITE =PN
ADDRESS
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OWNER
CONTRACTOR/DESIGNER/EN INEER
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S.Paq BERWARMNo CA 92—A08
VAN BERNAMM
CA
92408
(909)381-6007
V13IX
2120
USE OF PERMIT
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RECEIPT
DATE
(r
By^ ;pec
DATE FINALED
INSPECTOR
is
r f .
INSPECTION RECORD
i OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_
.a1Ci ��Q7�
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck .
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
-
POOLS - SPAS
BLOCKWALL
APPROVALS'
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
'Equipment Location
Underground Electric
Underground Pibg. Test
Final.
Gas Piping
PLUMBING APPROVALS J
Gas Test
Electric Final
Waste Lines
Z,� moi=—O'K
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
Final
Utility Notice (Perm)
A.
INSULATION CERTIFICATE IC -1
45-925 LA REINA COURT LA QUINTA
Number and Street
Riverside
29563
City
17
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 Tvoe
A. Cavity Insulation
Material BATT
Thickness (inches) 31/2
B: Exterior Foam Sheathing
Material
Thickness (inches)
4 FLOOR OVER GARAGE AREA w
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 Si ature, Dat ' 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
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