0012-254 (SFD)LICENSED CONTRACTOR DECLARATION
I IJereby affirm under penalty of perjury that I am licensed under provisions of
chapter S� (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
1013 1121
f Datej!''/%!� 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).
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
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of. perjury one of the following declarations:
() .1 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 mainiain 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:
Carver Policy No.
GOLDEN RA10.1111t MO.,
(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, -forthwith comply with thoseprovisions! i.
Date: 1. /'�f� Applicant is • ;a'!J.�.!f11.%' % ..
Ya w
arning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $160,000, 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 urider,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::
` gnature (Owner/Agent) ?�, <�� Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT Y�4%J•+r�+ I w 9 TRACT
JOB SITE APN
ADDRESS , '"M A VF_W DA LAS PALMAS
OWNER CWT
p 7� �y ��9�.s +p y�1,��ppe CONTRACTOR
y//DESIGNER
`/�ENGINEER
r 6� r�+��y
�..�L!eG91J,Ent 1. CRH -0 -WELL Cil.7�1 AW.S+1.P'AMS G!at`Q'1�l/Aru.`,Qxi+ROWIELL'•lwr�..KSMONAl.,l1:.f�1
15.5 ,13.01 n17 IMRI! L"Olm142M l i,Y15 So, 'v 020
SAM BERNt” O CA 92409 SAN F12I WARDANID iCA. 92400
(909);401.6007. CEIR 2120
USE OF PERMIT
Stela= '..LAN:S1301Z LS3T:8 QPKAMIT 9 61LS Noll, INCLUDE
i:11LOG~i WAL-1 O.f'001,611RI1+:•EWAY APPROACH.73% P1,.N_N C14i;`+C'K VEX
P,VD IUCT1:MI FOR R15•liAHCk* 0r SAME PLAN TY'PS,
TRACT C01OT IC'r10N 2^000F
}oOIRCHOATIO 48.00 Sig'
PT9R".TN1W11F SUMMARY
C( 1ti1.S1` °.iC,'t101`T ,"A
) 01,1000-• 3 04000 M1150
PLAN CHECK. 1 3
tCiflnCfOU•�i•��-�30 $1.dC,,O�
MEC13AXICALM
101.000.421.000: 8,53150
01;i�..0'f'kllC,t�.L.'.t�E:;
g•0�••t�t?C►�,y'2Ci�OC?('1 .. St1�.12
�-•�
�'�
STRONG, MOTION PEP, R8SID
101-000-241-000 SP1•"��
c"�
y t-;
OR-ADINO
10 l �CKdS�v? x3wEt00
V F'1OP101, IMPACT JPR?
$1,907.00
► Ci
r' rl (.D
M34Vd.ALCOltiiSTRITC";cIO 1#WyD''1��;�Tp,�WITC� 1qyEc,1IE,y
3,(a
d�ryry' r���•t
rwl,l,Y•J�,P]LlV •➢.•niF,eA�
q�.yG
YYV.Sl�{..bbRAL1ds/lFFAS1
• •L1NY��7
NO4
gY�i�
RECEIPT r
DATE' ( 1
BY �y
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs / _ s�
Underground Ducts
Forms 8 Footings _
Ducts
Slab Grade 8/Z9 ��
Return Air
Steel A
Combustion Air
Roof Deck _
Exhaust Fans
_
O.K. to Wrap
F.A.U.
Framing �p . 'ek,
Compressor
Insulation
Vents
Fireplace P.. yy
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
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
Heater Final
Water Piping l
Plumbing+inal
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral 9-
Pool Cover
Sewer Connection`. p l l
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 44 7- n
Utility Notice (Perm) _—U f
INSULATION CERTIFICATE
79-365 AVENIDA LAS PALMAS
Number and Street
LA QUINTA
City
IC -1
Riverside 29563 8
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
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 nature, Dat 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