SFD (9705-020)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
734281�/ U
f
Date p —?- � Signature of Contracto � f�
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
erformance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
S, c 'on 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.
(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' compe`nsatoi n -provisions of Section 3700 of the Labor
Code�t shall fort With comply with those provisign � � �4y
gate: � ? � Applicant •^-^�-�.���
Warning: Failure to secure Workers' Compensation coverage Js lawful
shall subject an employer to criminal penalties and civil fines upl°o $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.
Ignmure (Owner/Agent)"ftl-� m tA I
BUILDING PERMIT PERMIT#
(V=1 M ti ,t
CONTROL#
518 8
DATE �� a� � VALUATION 24��.�.?<�i 2U LOT [ �:L 1 TRACT
a,�
2N.I tft
JOB SITE
ADDRESS 4 1130--mcltlio
APN _
OWNER
CONTRACTOR / DESIGNER / ENGINEER
K-31, LAND Cf;�RV
KS1., ,PIEV1s J .11sif:Mr COW)
i6140 FGA BLVD
46140 PGA HLV1)
I,A OUIWA CJS. 'a7253
I.A Q151NTA CA 42251
(70)371-3642
CAM 4676
USE OF PERMIT
5111a - iii -.It TAGL. PLAN' 28A
PLAN C'"'FiClti V11% K0.)Wfill 7.914 PEJ.ft iv![fi;."f`!!4,13% IS UANC:E 01� `lANIF
K AN
P6 (ERj A•.F'.t0 _tfAM) SF'
(7AI<iA(ifs/(,6616Pc�k'1' 677,00 SF
rMIM't'EDC-MUOYCUNS°fttUCTION
241,839.20
���:"It1A��'�' il<'.�►{: ;�`ftitv�Ii�Atlw�' �"
""
4'(_'1N'811Z (VK N 1,11H t01-01,419-000
PLAN 41744w:CK., F!;.*E Illi -M)0.4 io -118
hf! LIIfi��.t''LA4 i`k it 101-000-1.21.-00
t f Ii%"1'IdiF j1t, i'lsli 101 4K)64.204" S171,Sti
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!►t 110HIIvto Fb331 101 -00040 -WO O S17q.25
tYiic3t`1O M1ty'!'i<tt?f t; ;lr. R.1111 0 101,M)_24I40D
r,lR A91PW; FlU. 101-C*042.140 320,6161
i NF ttli'a E`ROC.,t Uld. I 'L5 225-W-44.,5-142 0_4324,6 4,6
ACCE
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• Al2'!' tiV' 1'1l1�f,EF;" f>t,A1::f?ti - F4E;'ffTJ i01-00�-245-Uth) $��.�l►
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SW- ICYl't31, c,'01<tqCWJCn0N UM) MAN CITECK .»�.
$7,53-JA7
LESS 1'f::1~-t�t111317.f'.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
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 7
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 74f Z Vy,
POOLS - SPAS
BLOCKWALL AP ROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
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 A
O.K for Finish Plaster
ALF7
Pool Cover
Sewer Connection
Encapsulation
as iping
Gas Test 97
Appliances
Final
COMMENTS:
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)
REGISTERED INSPECTOR'S WEEKLY REPORT
J®N TANDY
®R,& 3610 Condalia Ave.
%6ccaValley, CA 92284
k9lgp, (61, 9) 355-5045
TYPE OF
PERFORMED
❑ REINFORCED CONCRETE RUCT. STEEL ASSEMBLY
❑ RINSPECTION 0 OST TENSIONED E NFORCED MASONRYRETE ❑ FIREHALT PROOFING
❑
THER"-'�
/REPORT
N.p
JOB 0 N
. e�er.,oc -I 114 vl,� c7�
SEQUENCE N0.
TVP FJLI�VRE / ^ �q
/V O'JtC`S'�
PERMIT NO.
DAe �� DAY OF WEEK
MAT IAL DESCRIPTION
- o �
ARCHITECT -
�R HRS. CHARGED
•IVIC,7
r
/
ENGINEER J
ASSISTANTS HRS. CHARGED
DATEINSP
GENERAL CO TRACTOR S. �e l� CONTRACTOR Y '�7..
(,jE
(A� e L%,0 c GQ LA
ALJ tJ P c -i olel C
ST73
S 7
S
6
COPY SENT TO CLIENT]
CONTINUED ON NEXT PAGE ❑
PAGE OF
I CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
SIGNATURE OF REGISTEFkb INSPECTOR