SFD (9905-021)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 # f•� ,t
al,Lfic. Class Exp. Date
- r
344237
`D to7 Signature of Contractor -'L
r 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.
Vl I have and will maintain workers' compensation insurance, as required by
Secti n 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 Policy No.
ZURICH INS,, CO. I&C 6I.W150S
(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' compensatio`n"provisions of Section -3700 of the Labor
Code, I s A II fo hw'th comply with t os e provi ion
Dater Applicant
.,-
IN6rning: Failure to secure Workers' Compensation coverage is unlawf€�I and
shall subject an employer to criminal penalties and civil fines up to $100;600, 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((purposest
'Signature (Owner/Agent),pe� 4! V D to
BUILDINGPERMIT FERNY#°NTR°`"
5189
DATE VALUATION LOT TRACT
2?.l'J7Ziid,,:31i 1, t4i 21t t I4?
JOB SITE
ADDRESS �t17j�I �dj 7PN
%6.-.J�IU
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1�c� a 'Q�117 [� E.,°` °�''1'
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6140 i'0A BLVD
(,:A iX lfNT,A CA 97253
LA QUIN".I`A CA 922%3
f7n4)177t-34.-12 <7SL# 4676
USE OF PERMIT
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PLAN t':HRX 9 VP. 75% FOR flr OL f IPL+, MSOANCE X3.1^ ,•31�iV4t?
iLAW
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S:1, 95►.613
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
50.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
p
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
7
Exhaust Fans
O.Kto Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
7/
Final
Final
/o ?%
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
6
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
S r Pans
O.K for Finish Plaster
Pool Cover
P&er Connection
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 4 -
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) i
0/7), ().p
_. A
N .I/A
�RE .SON TANDY
CQ3580 Condalia Ave.
6cnca Valley, CA 92284
e419) 365-5045
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE' TRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑ O
❑ OTHER
JO C,g,T10N�j' n. �'"•! • w ` A
�S�PECTO�
REPORT SEQUENCE N0.
OF , URE
JK,/�
PERMIT NO.
DATE
DAV OF WEEK
MATE IALXCPTION
ARCHITECT•
INSPECTOR 6dCS
HRS. CHARGED -
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL
CONTRACTOR
SUB
L (Q•2U (•- - CONTRACTOR
,^
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ONTINUED ON NEXT PAGE O
PAGE
OF
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 SECTIONS OF - THE
GOVERNING BUILDING LAWS:
SIGN�UR
URE REGIS
17
�S�PECTO�
DATE OF REPORT
REGISTER NUMBER