9909-088 (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
f�d188 13 IUf31f't?
ate �_', F %� 'a 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).
( ) 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:
CarrierGOLIDEN' EAGLE INS, Policy No. `fJWC 5006"1
(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.
.Er
�. �x Applicant—
ate:
77
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. 1
Ie"gnature (Owner/Agent) C 'a 1••' �i DateF/
BUILDING PERMIT
DATE J / VALUATION `��' 1t.S12't;') LOT
JOB SITE
ADDRESS
OWNER
C"•.Clk tURY C.ROWELL z;C:1141C+'S W IN
1335 90, "0" gCkEgf, S' - 52()(}
SAIN BUNA13 DINO CA 92408
USE OF PERMIT
OR POOL
PERMIT,./r9 =()3g
It; TRACT-�tiY31,
APN
CONTRACTOR / DESIGNER / ENGINEER
C11UrURX CP,OWEL L c.,c)mmu..Nn'ii ,S
1:35 SCI. `'D" STRR 'Fr, M. 4200
SAN 13Et?:F.vARDRZO CA, 92—Ii LS
(909)_4814407 OBL0 200
` RA(. it t'ONS'.1`IRUC TION 1,460,00 NY
GARA(T .9CACdK)RT 4 0.60 1
EST If MA I' OD COST OF C1;3NST3.dti.Y
.FION
PERiY IT PEE SUMMARY
M.NSTRtAL'T10INF`M,
lot-00'"Itz-000
PL Ala CHIE K rTu
10 11.000-439.31 k
�459.sa
&.1Ec'>"iANICA1, C7ii!
101-0%,421.-0no
547.90
1 4 E' RWAI FRE
101 -OW -4204M
b107.86
PLtWIRIN
123,7.5
STRONG MOTION FEL' - WAD
'101-000-241-000
X3.714
GRADING c141
1101-000.123-000.
521).60
tb'h.,4/tlC}P t{ IMP,RC T FU;
S1,gt -o')
SLID -TOTAL C0NS ir`W tl"`.t'10N AND Pf,,V4 r��"HECyll� � { X3,2')4.3'3
7. &S VRE-P�i.i�i Yi:i.k7 it (sit
RECEIPT I DATE
'g'+U'I'A.€, PERMIT F EEN DUE NOW 1 53.294,39
DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
. Z - @
Ducts
Slab Grade
%Return
Air
Steel
_N
Combustion Air
Roof Deck S - i -6t
Exhaust Fans
O.K. to Wrap
- IYj
F.A.U.
Framing
•- 7-1 -M
Compressor
Insulation
—z.f-o6
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 �C�{ c7� ��-f't�
BLOCKWALL APPROVALS
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 c D - ®Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
51~3 74R�
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final Moe-
UtilityNotice (Gas)Oj
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)
COMMENTS:
09/08/00 FRI 14:08 FAX` 0002
F ,
PRINTED BY CAMBRIDGE BUSINESS FORMS • SALES ;6161 568.5555 FAX 4619) S 3.5mo. • . - - , '
OWENS•�ORNIMG , 1
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aiming 1nsu1s t"oh'
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The contractor named below certifies'that the Owens-Corning Fiberglas Building
Insulation used carries the NAHB Research Foundation;'nc, label for assured
thermal performance and that the Building Insulation is installed in conformance
` with current energy conservationregulations, California Administrative Code, .�
Title 24,'State Of California, in the building located at, `
jzi n LA QUINTA 23995.8 LOT 16
Ad(Jr@SS _ City , Tract Number
>,
w Exterior Walls BAIT - 13112" R•13U
Owens_Corning Fiberglas Type Insulation'
Thickness R•Vslue
gAn 12 R-MU a e a "
Ceilings •
Co. Owens-f prning Fiberglas Type _— ! Insulation '
Thickness 1 Value z
fi Owens-Corning Fiberglas Type- �" Insulation _
Thickness R-Value
Foundation Wells
` 1 Manufacturer Type Thickness R-Value, .
Ganaral Conlractor, ,...,.._ .-_ _ ` License No
By _ Title Dete
Isgnn�rel 632072 e
Paragon Insulation License No,
Y
• InSNf3ljonConti- yr ._ •
{� SEC
BY Tine _-... �_ Date
1 � OWENS•GORNINGKtet?RGLASCOI7P.
'ub No K•aGu�26 ' ,Inaulet-onOperating Division
,ano+nUS.A..Seoi tale Cppyngnl,. PlberglasTower. Toledo, Ohio 43669
1
HOMEOWNER CQPY
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