0307-105 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
C�Mapter 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
. B iF[C 03/3112(
Date r -+r 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.
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 PEWOEk`R D E,-LPWY Policy No. 'f IX- -109040-2
(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 provisionsof Section 3700 -of the Labor
Code, I shall f rthwith comply with those prov610Ks.
Date: fnf ��.i, 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
4` 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, inde
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and v i
work is not commenced within 180 days from date of issuance of h
permit, or cessation of work for 180 days will subject permit to cancella n.
I certify that I, have read this application and state that the above informati n i
• correct. I agree to comply with all City, and State laws relating to the bui ing
construction, and hereby authorize representatives of this City to enter
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �' �w � ? -A 4 Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT -7 TRACT
F `
JOB SITE
ADDRESS 54-6". TCrtll�_MA, .
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
MIM.TOBN POTTkR
13Oi31a.Dt�'.�R COMSTRUCM014
5441673 RI1YMRA
79.920 FiMA DME
Tv.AQLM11da CA 92253
LAQULNT'A CA 92.253
(760)77.5-7933 C.BL4 521"
USE OF PERMIT
RFMEW..I:T,A1..AMTi` 014
,ATRIUM KOC:1,0SURF pip x)
CUSTOM CONSTRUCTION 1.24,00 3F
>CsiM'1:.t3..'7CED COST OF Cf,►.1+]'SxT1'UC",! 0,N
�3,Ci�5+r410
PLAN CHECK FE& SIMS
CONSTRUCTION FEE 1 td1-tZCi4i-d,1 t:+-ti00 $117.00
ELECTRICAL FIZ9 101.000-420-000 $12,50
Pi.oTyMB1140 O'4..1w 101.O�n-Q1 J�a00 $2t.bfl
STRO14.0 MOTION •1 - REBID 1011 4aA 1.000 $,97
'
A/ ZC l�ANICAL WE 101-000-421-000 X19.50.
-D PLAN CE�Bta-lOTAL CCZ ST )COAF
257.02
LJFM PRE -PAD FE F.9
D
$0.00
T4717A1.'. MOW FEES 1)UE NOW
17.02
AUG 25 2003
PITY OF LA QI IINTA
FINANCE DEPT
RECEIPT
DATE
BY
FIr ED
ECTOR
INSPECTION RECORD
r OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
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
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
IN,
SPECIAL INSPECTION SERVICE
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
78-194 Elenbrook Ct.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
O POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑ REINFORCED- MASONRY ❑ FIRE PROOFING
JOB LOC!TI N�(v� C � ^ _ � f o
_ 7 P L v�
RE RT SEQUENCE N0.
TYPE OF STRUCTURE �!
s 3 \ r`
PERMIT NO.(%�
`F%� ` Is
DATy
��
D WEEK
�i
MATERIAL DESCRIPTION[ENGINEER
RCHITECT
INSPE TOR
HRS. CHARGED
ASSISTANTS
HRS. CHARGED
INSPECTION GENERAL UB
.DATE.. —CONTRACTOR ._- _� -��'I�la�.�Vf.� CONTRSACTOR_
2
�bscr '�j o
rt� y k1 rn �^I rk. ycs e c r� •� �s�f
r�
'
2 3
COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE O
PAGE OF
.y CERTIFICATION OF. COMPLIANCE
i HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTION'S OF THE
GOVERNING BUILDING LAWS.
�./ 6V�'4.J cri..
Z^ IG T RE OF REGISTEREDtPECTOR
`o}, lc�Sc7�J7-c� ,
CITE OF REPORT REGISTER NUMBER