0012-251 (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
Profe,�;ionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
i 14131 '' t....r* ,•� ��
Date Signature of Contractor �-Y �'j _f'��-�-M3=
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). r
( ) 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.
CsC9bo -0 Etm4 'rci3 33!xw, s'R � -5 4063-02
(This section need not be completed if the permit valuation is for $100.00 or less).
O 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 shallrforthwith comply with those provisions. �?
Date: 7`7'r'',,. Applicant ✓tib ir`S
Warning:` Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of 'compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quirita, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter, upon
the,6bove-mentioned property for inspection purposes.
t Signature (Owner/Agent) 4 % if � ps Y till a 1 Date -17
� � '"'•� f��r
BUILDING PERMIT PERM T#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
79-41.5 k$V'.�.i°�iIVA L -AS 11 .a1MA S
604-W.1.41119
OWNER
CONTRACTOR / DESIGNER / EN (NEER
mrf(IRY 1171ROMLL (1101A vT,i3MMISS
CE Tnl' RY.OW0.1, C0MNIOMfL1.i3rS
1115 y;5 140. 111,0 I,f M11 1. 'UT.02. IN
35315 010. T11 ItirMENE, M 42.00
H;%A3'Mt"A�M0D40 CA 924.08
5, NB1,:FW:fR3:`+INO CA 92408
(:909Y.181 -60w 1claui 2120
USE OF PERMIT
SAO, Y1i ANM',55'0 Wji:3-PFRMIT M.4S NOT 1NCA':IULWIT":
,:WAE,IJPOOIA)3U`ti(;WAY',APPROACII,",�i?i, lialA"N C€ ROK ME-
RM"i9i`.TIONE+'CBR'ISSU,ANCEOFiAt1 ?, PLAN TYPE
T?t LIC T CONSTRUCTION ' ZoDN 40 SF
POR PA`9IO' 43.00 VIP
GAR AGEICA6tPORT (51F)
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:E:'fn-mmm co s`T oir C O.Kak:twanom
w .y -Trl rt846.00
PLAN CHWIX val 101-000-439-319
MMC>dDWO-Al.ME 101-000-421I.00CD ssmo
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P3,,UM9114113 FEE 101.0300-419-000 8146115
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S M M.(:;rTJON ME - T�`P`. aEI9 1DI -000-211.000 �1 $, (�f
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[; ,> i'r$ 31?C ifi3�d t3a �3�tPtYO 1)20,00
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b`I EJ��1.I \..�.LCti�e' C.IdXIC C1,kJC:.r..0 tw 4.bVSt1 tp�JJIACV �.a.E'�.lJi.�.F`.,•
yS�A7��, C?C?
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
;t -A us-
Underground Ducts
Ducts
Slab Grade
Z��
t"_> `
Return Air
Steel
Combustion Air
Roof Deck
�� Zc3
���yf,
Exhaust Fans
O.K. to Wrap
Framing
3 (Z$
141.V
��
F.A.U.
Compressor
Insulation
Fireplace P.L.
L q
�
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
t'(-� (►T
�g
Final
BLOCKWALL Ay -r PROVALS
Final
POOLS - SPAS
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
'_'epi—
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
,-Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Za
C pV* c
Pool Cover
Sewer Connection
Z�?,G
(
Encapsulation
Gas Piping
Gas Test,
Appliances
Final
COMMENTS:
Final C'
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 �3
Utility Notice (Perm)
INSULATION CERTIFICATE IC -1
�``''Z915 AVENIDA LAS PA�L'MAS� LA QUINTA
Number and Street City
Riverside
29563
County Tract No Lot Number
Description of Installation
1 ROOF
Material
Thickness (inches)
2 CEILING
Batt or Blanket TVDe BATT
Thickness (inches) 12
Loose Fill Type BLOWN IN
Contractor's min installed weight square ft 0.615
Manufacturer's installed weight per square foot to achieve Thermal
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
Brand Name
Termal Resistance (R -Value)
Brand Name CERTAINTEED
Thermal Resistance (R -Value) R38
Brand CERTAINTEED
14 3/4 inches
Resistance (R -Value) R38
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)
Material Brand Name
Thickness (inches) 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 ,wh4applicable.
2, 3A 8/6/01
Item #s g
Item #s Signature,.Date
Item #s Signature, Date
PARAGON INSULATION
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner
Installing Subcontractor (Co. Name) OR
General Contract (Co. Name) OR Owner