SFD (9905-019)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurythat 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
r°41,8; *a'���,,.
r.•D41�'X-Signature of Contracto'i,4i��. W U
a
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.
II 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 Policy No.
ZUR411 INS, W. W4Ctuf:lf;�ui�s
(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 provisions of Section 3700 of the Labor
Code, I s all forthwith comply with those provisions.
Date: �a �� �./�ir Applicant r �'iL.a'"'{''r,� I •�
Warning: Failure to secure Workers' Compensation coverage is unla of I 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 pu
property for inspection purposes:
est
(Owner/Agent) �( Date5
/7
BUILDINGPERMIT PERMT#
CONTROL#
5187
DATE '1122/97 VALUATION . LOT ; TRACT
( IIrY
JOB SITE
ADDRESS II';ZL[��4tiKt
APN
�if1Z-��D-�YU
OWNER
CONTRACTOR / DESIGNER / ENGINEER
3oIMh t.APSS? 11 i'Ajl:a,k8l,
D"VVVL[),:'A;I Rd',!'f.`c)iu)
KJrA BIND
its t �W .PGA iii, to
(,A QUINTA. (�A Q?'M
LA. (',)01INTA.
CA 417253
1'!t"�Oi•i`�I d3fi47
f�;itt.# �fi`14'
USE OF PERMIT
SFU - IRikf As.tf ' PLAN :'ti k
PLAN 014HXX *' SAW,'
(:CJS`:<:iivf t:' NS"1`I�t l�`I"9C!Ai 3,443,00 S
P tt �i��A'i tib 1, 19,00 S3 ,
GARAO'l-A''Af POR' -I` -%4A 1 8F
r;STINIA Ef D COST OF CONSTRUCTION
„ a(,.:5 UAV)
CON STRt_C .KYNF�LE 101 -W -4184M 3t.294A)
Ptv+ N PFT 110,73
�t ,
j4fi.2 is�2�3`[C°AL hk E tGl Q 21-000
l.l.ls€,°`tAWAL blit. WI-.0t1i' 420-0W S169 fd!
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ADINGFM 101.000-423.000
tNFRASTRUi'. OeW FIX. 225-iiQ 44_�-342
ART IN KWIC PLACES - .RESIT) 701.000-M-000 1465.%
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81 WOUTAf, C (-)N9 TRS ►CT10N AND MAN 000K.
LESS
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TOTA11:, MMIT FNW..S i 1TENOW
S"'Swo
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APP OVALS
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 0
Compressor
Insulation71 7
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
%_4
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 I 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
Pool Cover
ewer Conn
Encapsulation
Gas Test
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)
City or
"; JUN'.30REcioNTANDY
BUILD11yG AiyR 3580 Condalia Ave.
c_ajyalley, CA 92284
(619) 365-5045
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE TRUCT. STEEL ASSEMBLY ❑ S * p
❑ POST TENSIONED CONCRETE ❑ ASPHALTTHER j
O,REINFORCED MASONRY ❑ FIRE PROOFING' Lxk- 61wCi_
JOB 1.�W(A/y�)pN ^) `' &REPORT
SEQUENCE NO.
TVP F STRUCTURE w
FO O C_J1t
PERMIT NO.
D TE
- 6-1
DAY OF WEEK
MATIAL DESCRIPTION /
L
ARCHITECT
INSP CTOR
HRS. CHARGED
_
ENGINEER
ASSISTANTS
HRS.CHARGEO
INSPECTION GENERALCONTRACTOR K •S'•l.. • Y��-�% CONTRACTOR 1
DATE
'w Q_U6 c-4 64- 46 AS 2 64_
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COPY SENT TO CLIENT
CONTINUED ON NEXT PAGE ❑
PAGE OF
1
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY SIGNATURE OF REGISTERED SPECTOR
KNOWLEDGE ALL OF THF. ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. i HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED(
`PLANS. SPECIFICATIONS: AND APPLICABLE SECTIONS OF THE_, _ lupi
GOVERNING BUILDING LAWS. ^`;�' �`^ '';DATE -OF REPORT_, REGISTER NUMBER
i