0105-0109 (BLCK)44996 Adams St
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
DateA.'
Signature.of Contractor - ; i + L -^
OWNER -BUILDER
I hereby affirm under penalty of perjury that ['am exempt from the Cont'ractor'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 a.. .}}.exem t under Section B&P.C. for this reason
DaSignature 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 q • 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/hermit is issued,
I shall not employ any person in any manner so as to beco(ne subject to the
workers' compensation laws of California and agree that )' I should become
subject to'the wor ers' compensation p bvisions` f Sectio fi 37Q0 of theLLabor
Code, I shat forth Ith comply with p e pr vlslol S. /' /
n ro•'f/ f l 3 e. , r r ""CSG/ , , d/ _ V 1 Y. l . _.. 'S
Warningl Failure to secure Workr's' CompegeationYoverage is unlahful and
shall subject an employer to crimi al penaltie and ci II fines up to $160,000, 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
y correct. I agree to comply with all City, and State4aws relating to the building
construction, and hereby authorizg4representatives of this City to enter upon
,. the above:mentioned property for spect ort—purposes.
'Signature (Owner/Agent) a' ' ' j I - ' DateC A.
BUILDING PERMIT
PERMIT#
DATE VALUATION LOT i',
Q TRACT
JOB SITE
APN
ADDRESS
44-996 AMAINIS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
E+rl RK SAMWOS
MK=9DEME opunri'M« R DTii1:i:MM
,()0 L i)T1BT cLU_A
67"0 FOWI TIVI RM,
PALM ii.PRNGS CA
=IMML My CAti. 922.34
(760)?W-6343 G51h 6206
USE OF(yyPERMIT
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346LF4' IMM141'N 131 WAU..-OR.CO STANDARD
500 LF V 0AT4;f EN 'BALL-ORCO 'wFiAN.i5AIW
13 ,L1r OW)CK 'CIIe1V, TRASH F,14C LOSURF-ORCO ;i°r:A'NYlARD
6 FT. WALL
513,09 LF
4 PT. WALL
LY
ESTIMATED CO 01 i:ONS'UO'T':iON
PERM! FRE SUMMARY
C!QNSri'RUCTION FEE' 101.000-418.000
MAY - 2001
8
CITY OF LA OUINTA
( y'('j ' ( yj' FINANCE DEPT_
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VIII III VIII IIII 15
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
a
INSPECTION RECORD
OPERATION
T DATE
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs I
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
BLOCKWALL APPROVALS
Steel POPLS'. SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I
Underground Plbg. Test
Final I
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
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:
I
a,
F
4 X4
w PUNCHLIST
OF T19
CITY OF LA QUINTA
DEPARTMENT OF PUBLIC WORKS
PRELIMINARY PUNCH LIST -
Tract No.. Tract 29288
Developer Six Kids Development
Date June 28, 2001
General Notes:
1. This punch list is preliminary only. All improvements subject to review and approval by
City Engineer prior to final acceptance. Deficiencies may not be confined to those noted
herein.
2. The City shall be provided with updated original mylars for all improvements to reflect the
"as built" condition. Each sheet of the drawings shall have the words "As -Built" or "As -
Constructed" clearly marked on each sheet and be stamped and signed by the civil engineer
certifying to the as -built conditions.
3. All monumentation shall be performed and certified by a Registered Land Surveyor. A letter
certifying the monumentation has been performed shall be provided to the City.
4. Certification letter from the Engineer/Surveyor shall be submitted stating payment for
services has been received.
5. The City shall be provided with letters from all applicable utility companies and public
agencies, certifying that all underground improvements are in place, completed, and
accepted.
6. All improvements shall be cleaned and access provided to all drainage improvements to
verify condition, drainage, flow test, and functionality.
7. Striping for parking lot is not completed. .Advised that it will.be completed on June 29,
2001.
8. Temporary Certificate of Occupancy to be issued on the premise that all issues stated hereon
will be completed by owner.
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