0012-264 (SFD)LICENSED CONTRACTOR DECLARATION
`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
Signature of Contractor' -44-1
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 & Professional's
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:
Sec)` I have and will maintain workers' compensation insurance, as required by
tion 3700 of the Labor Code, for the pelTormance. of the wurk fur uuliich thi9
permit is issued. My workers' compensation insurance, carrier & policy no. are:
Camer Policy No.
EAGLEWIN . N I- 9LS3�U2
(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 s 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, l shalliforthwith comply with those provisions.
Date"; 7 6�,T%J?Applicant �rfj
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. Lagree 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)R,... )r�'"f ��� •{�%��/�' � Date )?12___r1
BUILDING PERMIT PERMIT#
DATE VALUATION LOT "�
TRACT
JOB SITE
ADDRESS
APN
4S- W. ,A)Rd=KA COU r
604-051-019
OWNER
CONTRACTOR/DESIGNER/ENGINEER
t1."URY CRSaWELLCO 'U.MS
CIN: LAZY f"i?CaWELT,100MIdUlir9"ES
1335 :Sia."�@ ST'l��T; fsnxµ3 R t1t2
153: SO. "SQA MRIN , S ro- 4200
USAN BE"itNARDWO CA 92408
SM BEliNtlR1:190
CA
SM408
(109Y381_6007
C.81
. 2120 .
USE OF PERMIT
S OS 1?fi11%1)r DWEL ING
S,I?D- NL;AN:19 Lrf?9'A PERM12' 1' O&S Z .)T 1NCI..I3D9
I1WG`ii,WtlC.+l..W100.0DR,'fC�'TfW:A,YAPSyWACK 7.1%PI.AN CF VIK, FVE
k1t f: UCTION FOR ISSUANCE 010 WMIE PLAN TYPI
T14kCT C ONSTRUCT.10-0 1,670.0,3r,
PORCl/p,ATIO 34.00 51p
�1tAtt.�,CiLrlCJ:lF�1'f�iLT ��� �,1'i��ZO
E5'.fi.ID4mm Cf. m op d`owsr .L#.'1;Y=oN
100,460.10
t.ONSTfiLUOTION FEE 101-000-418-000 $643,00
r- t
PLAN CREC1v FF Le 131.000.1439-31.6 $131155
MECRANICAL nl- 131.000.421-,000 $5:3.50
ELEC d'I:IC.AI- >�ir y ' 0 ► r000-420-000
I'I,.1r?M'SINO3!PZ' ' . 101-000.41:0.000 SIXIS
STIt[6X+IGi MOTION=, - R 'SID 101-000 -241 -OW
011ADINO RT 1>a1.,000 5-Uf►Ci 42Q,bU
'rr .
DE1 ?J40PPIR, LF,9PACT 1EP,
1Wr(Y3°AL CONS': RUC ION AND PLAN CfMCK..
$2,996.46
LE 33 PRE -PAW A03
$0.00
o
. ��'S/Ari=�1ld:¢'.•..•.�ct'►.�.it.fi��,�!I��fi9J.�r 3tl•W 9'� .'
��i�i�'9i�
RECEIPT
DATE [
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS'
Set Backs
2 t��
Underground Ducts
Forms & Footings
21 CpS�}�
Ducts
Slab Grade
r
Return Air
Steel
Combustion Air
Roof Deck
Zs.e
`}�
Exhaust Fans
0. K. to Wrap
u
F.A.U.
Framing
(
Compressor
Insulation
71p �(—t��
1
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
Final
oT �dr�
Final
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
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
2\� C_
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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
INSULATION CERTIFICATE
45-905 LA REINA COURT I
Number and Street
Riverside
29563
` IC -1
LA QUINTA
City
18
County Tract No Lot Number
Description of Installation . e •
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 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 anc 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.
2, 3A 8/6/01 PARAGON INSULATION
Item is i nature, ate 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