0012-253 (SFD)LICENSED CONTRACTOR DECLARATION
�f 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
;' 7141 B _ 1 t)% 11/2(
Date r/ 8/'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:
( ) 1, 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
-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 3.700 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 a�A No.
0011D.EN EMILIE YNS. . '
(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 with4hose provisions. {,
7�a
Datre: ,-a •�y Applicant`.` ,w v ,•f . r ,
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. l
ignature (Owner/Agent) �f + +j �!R� • Date �-ele,,
BUILDING PERMIT PERMIT#
DATE VALUATION qct qtI��rQ� LOT Q3•- TRACT
JOB SITE APN
ADDRESS .� �p� �y�y+� * @� •p y ,��p, ,�,'g�y +
'-. /.rid A 7.iE:•,sF.V.i�'�:..li,e��. ski` �1� ,f`.4�..+L'1 ms, 'S �U�`i^W 1-4,1119
OWNER I CONTRACTOR / DESIGNER / ENGINEER
C URS' CM^ftN:a 1,E i++ R dT�.t�'�ri►s �t..T., ! ;,,M ��L32+�;C€'f[U,
)535 Sri, 0. anpwv , T, . 00' 3.535 SO. V, �3;I'i'4yE1, M #200
3" WaMAMNO VIA 92409 SAMMINARDINO M 92.408
(5K)9j381.6007 =X, 2120
USE OF PERMIT
MOLE FAIVULY UVOIA40
:!37Dae-?�C7�)•,+gfg3���13;`SfG`fO#y2y��y,Cirr..'•��-PLE,sa���pei°%pih7gf3�S17h!1f:3`flT+ti�i:lJzAtFEILK1t
S. ille�j 'Ic �y [
.C.1 .M1fi..lb•w1,YiIr7AQ4..��.a'AN NL�7.V L' iT.[Si�.IR7',R3S4.,V�.�,�L/. FJ'�IO ,I�i.ea'i.dV 1
RUDUCTIO N FOR IM51LIAOCZ OF % rid: MAN TYPE
TRACT CONSTRUCTION ;oDsm 'sF
powcwpAtlo 43.00 SF
l�t,'�INATKO Con OF a) le'_fi�UCT3rO
CONSTRUC'•TION 1,11
1fl:g^E217 +$If �Gt4i !
3i >S1�
.PLAAXC.HYCK:I;EW
Sita- JOp$ ' T
'.. .Ddtl.fi3
MECHANICAL LAICAL MW
101.000.421-000
1-000-410-000
I a f p
FLAiM� 040 1
1 C►71 � GL' 3 *t➢tlCf
g14d.74
STi+!040 Mt'rF.ION FOY,• RESID
101-000-44'9-000
4OP? EADPAO WE
103 -0004232 00
D1r,"il'M.k' PXA IMPACT Fb.'is
b1,51�P.Oi3
%M TOTAL.CORWR C70 NOW MD PLAN MEM
LESS PIZ a'-IA:.'1� ;ties
117,046,00
'71
}4
$0.00
TOTAL .S► VOMf a:Ja'L# DDIP, NOW Y .. $3,( W.,
RECEIPT bATEa ' ' t t BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
APPROVALS
MECHANICAL APPROVALS
Underground Ducts
Forrhs & Footings
CO
Ducts
Slab Grade
Steel
Roof Deck
C�—_
Cs
Return Air
Combustion Air
Exhaust Fans
O.K. to Wrap
Framing
Insulation
, Z _
u�C1
F.A.U.
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior lath
Drywall - Int. Lath
_
Final
Final
POOLS - SPAS
BLOCKWAtZ
A PROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test -
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
Z 1
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
.Sewer Lateral
Zfr?p
Pool Cover
Sewer Connection
Z%2A
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. 01
Smoke Detectors �J
Temp. Use of Power
Final
Utility Notice (Perm)
INSULATION CERTIFICATE
t 79-375AVENIDA LAS PAL
Riverside 29563
LA QUINTA
City
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 Tvoe
A. Cavity Insulation
Material BATT
Thickness (inches) 3 1/2
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 Complian e, where applicable.
2, 3A 8/6/01 PARAGON INSULATION
Item #s nature, Dage Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Item #s
Item #s
Signature, Date
Signature, Date
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
r)