0042-297 (SFD)LICENSED CONTRACTOR DECLARATION
.I hereby affirm under penalty of perjury that I am licensed under provisions of
p 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
s'111188 f3 ,�-112r31iN1
vD e � �GSignature of Contrasoor ��
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 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.
(X 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 I-X)LDVIN AC1 E 11115. Policy No. t4lwc 5111106$.-01
(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 .5ovisions Of Section 3700 of the Labor
Godeshall forthwith comply w' -t•fe provisioris.
Applicant �-
Warning: Failure to secure Workers' Compens` tion 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 inspectionp rposes.
gnature (Owner/Agent) / Date
BUILDING PERMIT PERMIT#
DATE VALUATION �!LOT 1_Y3 > TRACT ;�3095-1i
JOB SITE 76 dZ.5I AN!,;H EZ4D WLE APN
ADDRESS/�/�
OWNER CONTRACTOR / DESIGNER / ENGINEER !! ('
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1533 90'17;"
!MEET, ME, ;100
SAN 1111-ANA,itDINO (`A 914W
USE OF PERMIT
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rRECEIPT DATE /o BY �> DATE FINALED ( INSPECTOR -�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
4(_ -ft
Return Air
Steel
3 - ZY-W
Combustion Air
Roof Deck
S - ( _W
Exhaust Fans
O.K to Wrap
5-1tr -00
F.A.U.
Framing
Is --y,Z -&it
Compressor
Insulation
- Z •{ -
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
U it -00
Drywall - Int. Lath
&
Final
Final 2
BLOCKWALL AP ROVAL$
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
Z, ��
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
ao
Pool Cover
Sewer Connection
` pp
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) �q
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 L k—
Utility Notice (Perm) 2Z oC9
COMMENTS:
09/26/2000 TUE 14:15 FAX
0009
k
INSULATION CERTIFICATE
tC-1
75-715'WAKEFIELD CIRCLE
La QUINTA
Number and Street
RIVERSIDE
City
Count
23995 •r�t9
Description of Installation
Tract No: ,
- Lot Number
1, ROOF
Material
Thickness inches
brand Name
Termal Resistance R -Value)
2 CEILING
Batt or Blanket T pe
Thickness (Inches) 12" "
Brand Name OV` ENS CORNING
_
Loose Fill Type
Thermal Resistance (R -Valu R -38U
+ _
Contractor's min Installed weight square ft Ib
brand
Manufacturer's installed weight per square foot to achieve Thermal
Minimum thickness . -inches
Resistance (R -Value)
3 EXTERIOR WALL "
'
Frame T e
.
A. Cavity Insulation
Material
Thickness inches 3 1/2
Brand Name OWENS CORNING
B. Exterior Foam Sheathing
Thermal Resistance (R -Valu) R13U
Material
Thickness inches
Brand Name
Thermal Resistance R -Value
4 RAISED FLOOR
Material
Brand Name '
Thickness (inches)
Thermal Resistance (R -Value) '
5 SLAB FLOOR/PERIMETER
Material
Brand Name
Thickness inches
Thermal ResistanceR-Valuep
6 FOUNDATION WALL
Material '
brand Name "
Thickness inches
Thermal Resistance (R-Value-
R-ValueDeclaration
Declaration'
I hereby certify that the above insulation was installed in the building
and the above location irl conformance with the
Energy Efficiency Standards for residential buildings (Title 24, part
current
6, Califronia Code of Regulations) as indicated on the'
Certificate of Compliance, where applicable.
PARAGON 1(ULA710N CO. ,
9126/00
12280 EAST END AVE. ,
Item #a
C1410
Installing ucon4r�ctor (Cc, Name) OR
General Contract ('-c. Name) OR Owner -
Item tts Signature, Data
Installing Subcontractor (Co, Name) OR_
+
General Contract (to. Name) OR Owner
Item #s _ Signature, Date -
Installing Subcontractor (Co. Na _me) OR.