0402-355 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
17,331 X32lIG r, 9/"30/04
Date Zh, /-x Signature of Contractor /,"/1//y"- ,' //t-/
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 ,
( ) 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 consen6o 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' compensations 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 OLD !$.t?F'f BLIC i180 Policy No. WKIM7900
(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 those provisions.
-Date: �/� !^ rl /.� 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
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 nullrand 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'
construction, and hereby authorize representatives of this City to enter upon_�i;;
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) /l/. 'i4/%/%r'y Date Z/1 JSI
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0402-3•!RS TRACT
S1 4,53O.W 25 29323 a
JOB SITE -
APN
ADDRESS 73 7s4!�'1�wo :UiFLivjr
OWNER
CONTRACTOR / DESIGNER / EN (NEER
'
IMTKARBONM F IryAR. nFORMA
I.INN A'R HOM-E.' OF CATI1 DTOUA.
78-401 C M01 -PRAY I I 1
78.401 C9 NIO 11N"AY 111
LA QURJA CA 92253
L.kQUINTA. CA 92,253
(',?60)177.0.131 (781At :434
USE OF PERMIT
SPD - LIDIF 1% Pf..&W :372.. FEfU-AI ' DOES N01' rNC''I U08 BL OCti. NI.A.L iA
POO" SPA OR DRJV PVVA.`Y'.APPROACH y
1'1°ACT CIONST1tUMICINT 'A121,0ti SF ,
PORCIrYPAITIC) 43,00 SP
0AP A.OWC,ARF°ORT 447.00 SF
Z91U .rW COST Of, C;.ON167 ;I�"d,TMEON
124,530,00
����yy qq,,pp�� �gq� 99 pp q;'; p,� {'p �y-
RE
C`.{'iidSTRUC,�^TIC�3 FEE 101-000-448-000 MAN
PLiAN 'b 7 }.�6aj1�, if1'7 101-000-4,3V-318 .097A a
MECHANICAL RX 101.000.421.000 347,00
f..l..ECT LICAL, IT -E 101-000-420-" $116.68
I'..IUMBING FEE.. 101-000-419-000 $146.13
STRONG MOTION FEE • l;.IESID 101-000-244 -0,00 $13.4:5
011JI U -N O' E19 W.00
DEVIYFL.OPER IMPACT PEZ
KYO-TOTAL C01-'2"ITUC'I"ION A14D PLAN C'T3IAt=
$4,067.29
Piw�'l3�11:� 1Aei1'u
' E R M �y'y�"'QR �a/�i�7•�
}+ g• • �^1 t� FEES
TO
APR 0 6 2004
�p',B♦4,�r{��
- iJ•y {�J �1�,>Y•.
CITY OF LA QUINTA
Fwr q►I+tCE DEPT.
RECEIPT
DATE ! 7.i
BY a . '
DATE FINALED
IN
INSPECTION RECORD
;? OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVA .S
MECHANICAL APPROVALS
Set Backs
Underground Ducts
_
Forms & Footings _
Slab Grade
Ducts
Return Air
Combustion Air
11 _
_
Steel
_
Roof Deck
Exhaust Fans
_ _
0. K. to Wrap `
Framing - '� _ _
Insulation �,/
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 I
Final
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 PP OVAw. S
Gas Test
Electric Final
_
Waste Lines _
Water Piping
Heater Final
Plumbing Final
_
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral _
Sewer Connection —' p�
P over
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)
ce'rflfievate 'flnsulatiow
f
Youir Home has been insulated with CentainToed Fiberglass Insulation products, which are designed
- for today's safety standatyis and tomorrow's energy requirements.
..-
-
Fiberglass is inorganic and therefore permaneody noncombustible, so it does snot have to be treated
rt
w th fire -retardant chemicals that will likely lose their effectiveness over time. It has not been treated
with chemicals that can corrode wiuing;or metal Fiberglass will not absorb moisture nor will it
settle over time as may ocher insulation materials_
:}
o
This also certifies that CertainTeed Fiber Glass hisulation has been professionally installed in this home
to provide the following thermal performance:
,Hob Name: Tapestry (a1 Esplanade Tract: 24323 Phase: 5
Lot lt.: - � Q$^ (Plan: 312 Address. 4tiVieotm-Dr,.La.QuonGa, CA
_
75
Ceiling Area: , R-38 Blown Garage Ceiling: Interior Walls:
With Living Above
Overhangs: Exterior WaUs: R-13 Uefaced Batts
Ceiling: Garage Wall: Cantilevered:
i
Inaccessible to Blow Floors V AUving .Above
Subco ractor:. QJI sulatio ,Co, Inc
(A0 5 n Azwss 702 (6 6) 9l 60 0 'cease )465 i 09
Signed—
co' C®nclli,taz oriizt, Secretrtr lTreasuJrer --r1r— Scod Jenkins, president -or=-
Lou Merolla, IDirecdor of opertataons Officer
c. .�
R• means resistance to heat flow. The higher the R• value, the greater the insulating power.
Q
Ask your builder for the -fact sheet on -R- values., Keep this certificate with your other
a
a
valued papers. If you ever sell this home, this certificate should, be passed on to the buyer.
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