0104-341 (GRES)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
c
:11
Dat `!� Signature ofContractor { +-<wl••r'
a Ln
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, Buslness & Professionais Cow).
( ) 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:
( ) Ihave and will maintain a certificate of .consent to self -insure for workers'
compensation, as provided for by Section 3700 of thl 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
Saction 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 1"E010H INS COX Policy No.
(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 sh pld become
subject t the workers' compensation" provisions of Section 3700 of the Labor
r . °I C .
CaoiSe, I s all` orthwith comply with+those pr Islons.}
Date:j ° r, APPlicantF'ti"
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.
MY'
i 6' A
,Signature (Owner/Agent)'„ , t' f => ;' �'9" "`� Date•f
{ .BUILDING PERMIT PERMIT# `
DATE ' VALUATION LOT 0104341 TRACT A.
JOB SITE APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/EN INEER
,5626a RAMA 79.920 i�:MDRIVE
I �:.%I ivid:Pe CA 92253 LA QUnIT'TA CA 92253
(760"1" -7333 CTAX, 3212
USE OF PERMIT
3533Y. G0LYC.AXrADD1TJ0N
laARWIN
:13�.A0 Sly'
q vey�``��r{ry RUM
gg ' 3yy�p"` mx) iC"o2a C'3y CC%�l's���'�.":i oli
A481°wY.�.SL�lUPEF Ci'0.r.F9f+17�[J�.tl.6.2�r
:f`IAN ME47lr: FEE '101-000-439-33 6 $50,50
CON TRIUCIION M. 101-000-118-000 $90.30
URCHAINICiAL N'Hr 101-000-121-000 $15.00
E1AC k'T C.AL. fee 61-000420-000 54(00
RECEIPT
S1: B -711t7:> A
DATE
D A �
MAY - 1 2001
CITY OF LA OUINTA
60W.00
ANP—*`' A4 ate I $204.20
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TaW' 2 R L FWRL7k.N C FFX',3 1V UE S'2O Y1r
INSPECTOR
94014.20
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
S ( !o
Ducts
Slab Grade
_/ O
Return Air
Steel
Combustion Air
Roof Deck
/�
Exhaust Fans
O.K. to Wrap
Framing
Insulation
=�� 8�0
���
�p (
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
� -
/
Final ��lMl l
BLOCKWALL APPROVALS
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top, Out
Equipment Enclosure _
Shower Pans
O.K. for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS: Q
I
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
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 LOCATI a
�-
REPORT SEQUENCE NO.
TYPE Y E
PERMIT N0,
D E / of
DAY OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
I
HRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL -.SUB.
CONTRACTOR % W CONTRACTOR
Col
Lt
0
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COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE (9
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV SI NATUR OF REGISIE INSPECTOR
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS. DA E OF jRtPORT REGISTER NUMRFR
-4.