SFD (0301-022)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
674074
;Date!'; , " '' Signature.of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty, of perjury that:I am exempt from the Contractor's
:s
LlcenseLaw:for the following reason:
•1
t, as,owner of the property, or my employees with wages as their sole
..comj)ehsation, will do the work, and the structure is not intended or offered for
;;sale (Sec. -7.044, Business & Professionals Code).
( . ) •• I,' as• owner of the property, am exclusively contracting with licensed
contractors, to.,construct the, project (Sec. 7044, Business_ & Professionals
Code). • .
O Lam 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: +
Se(f ), I. have and will .maintain workers' compensation insurance, as required by
ction 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 , _STATF; :i'frND , ' Polioy No. ,. 046,7413-20.03
(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 -l -should become
subject to the workers' compensation.provisions of Section 370Af the Labor
Code I shall forthwith comply with`those provisions.
Da't'e:% ;. Applicant:....._ -- t.•
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 he 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, rVnify
& hold harmless the City of La Quinta, its officers, agents and em bes,
2. Any permit issued as a result of this application becomes null an � d if
,work is not commenced within 180 days from date of issuance f s ch
permit,'or cessation of work for 180 days will subject permit to cane t n.
I certify that I have read this application and state that the above infor do is
correct. I agree to comply with all City, and State laws relating to the uilding C!
construction, and hereby authorize representatives of this City to' ent r I
the above-mentioned property for inspection purposes
Signature (Owner/Agent) •
'.,-..BUILDING PERMIT PERMIT #
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TRACT
DATE VALUATION, y��gfny�g - LOT
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JOB SITE • '
ADDRESS`
APN
OWNER''
CONTRACTOR/DESIGNER/ENGINEER.
'11) ��:+;SaER`.!`' DROVE:f,.,OPINIENT
VAMCS C"1098"RUC;'. 014
1--p BOX 1716.I
A.1UGI "% ,DR.
. QUM'A CA 92253
u& QZfw3' , O- 92213
(760j711«1941 CITL4 29%
USE OF PERMIT
MtSI✓. 1r yi,K,�l'+�l•E�v y y{q� y' q pppP
f
5PD � F.,C,7T 4;k 'PLAN R1. I?1+.�'A/1►'� f7v�f�:1`iPi��' I2�'C irttl.f JIE 3i,rOi�L�'
1V;>Q&6%- P664 PA. G.tk. €agd VFWAY A.PPALOACK 75% PIAN t;:HEC.'•)': EY,
REX) $C7 OW FOR. ARY.PLX1PT.-° ISSUAM OF-304E.►f A14 TYpk
CUSTOM COMPYRUCUON 2,635,06F
P0P.d?F1i`?XrI.O 267DKI W
0ANAMUCARIPORT SP
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221),FZ2.00
C�C9t�3T'1��C'�.3c�� #•'x.=:19 1€�1�(=x'41 f���49D �D�ti3.4�
'
'PLAT4 CHECK FEZ $31-7190
ME.C°HANICA1, PER 101'.000-4,21-000 -4,21.000 3115.0
EirrTaz CV,:rr-M, 01- 000.4 0--000 $102.01
STWMI MOTION kms: _ .1USMD Y Ol _�lf�-7i°•'1-bi�3i) �2�:49
ORA.w.wlVa.; 1�3YQt3C1��.5�?OL'1 �9�'E�
t}3rtf'Zi'L011HIR, 0.I3?ACT PE
AAT tO P1,18LIC PLACES 05.1it VO -OW -445-000 W.13
�Q�'£� .-TC l:A. fa:C)'�°l `,�'�Fi�.i f..° `�.ON AND, :f ?"i..,t INY L11 MI.
n 7-33 k�.R.� PAWI�1�€,3
$0.00
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'ENDUENOW
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PJ 2 2003. �
2
'Lp _F•. LAS CTU141A a
4 r
h
IMAHCE DEPT.
RECEIPT
DATE+'+
BY
DATE FINALED
INSPECTOR ¢ rGtt
x�
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
..
Ductsv
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
---3
Exhaust Fans
O.K. to Wrap
-- 2 _ 3
F.A.U.
Framing
- ;z S e 3
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
_ 7
Final — -
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
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
Shower Pans
��
Equipment Enclosure
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) Air—
COMMENTS:
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��k Lk
INSPECTION
REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
POST TENSIONED CONCRETE ❑ ASPHALT
TOO REINFORCED MASONRY ❑ FIRE PROOFING
❑ OTHERPERFORMED
JOB LO ATIONQ
REPORT SEQUENCE NO.
TYPE OF STRUCTURE
-
PERMIT NO.
cb — 0 22
DATE
3
DAY OF WEEK
M ERIAI DESCRIPTION
i
`9
ARCHITECT
INS ECTURR
0..
HRS. CHARGED
_g
ENGINEER
L)
AS
MRS. CHARGED
INSPECTION GENERAL sue
DATE. CONTRACTOR. 1. — _ _--CONTRACTOR
�—s—
Ji M
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2Q S
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COPY SENT TO CLIENT 0
CONTINUED ON NEXT PAGE
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.
VV
I NATURE OF R ISTERED INSPECTOR
3 ICQQ�5-077-111-:5y
TE OF REPORT REGISTER NUMBER
s-
,SPECIAL INSPECTION SERVICE;J
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 , L4 t[
INSPECTION
PERFORMED
O REINFORCED CONCRETE O STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
O REINFORCED MASONRY ❑ FIRE PROOFING
Ok
❑ OTHER
JOB LO TION
— `7 (A
REPORT SEQUENCE NO.
TYPE OF STRUCTURE
-
PERMIT NO.
-1 4— 2
OAT
DAV OF WEEK
,
MATERIAL DESCRIPTION
�
ARCHITECT
INSP CTO
HRS. CHARGED
4
ENGINEERS10
Gov Vis
ASSISTANTS
NRS. CHARGED
INSPECTION
DATE
GENERAL$UB
_ _ CONTRACTOR -S C>f a�(� . CONTRACTOR
--
3
S i M S�l1
QJ
v %j
' 2 ov 0'S C-
IJa ie'.
06
P. Q . (p -7
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE
OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT 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.
cn�o krz� tj-40,"
GNATURE OF REGISTERED INSPECTOR
3 Z 3 _T-gco S01 -1 -t1 -I -8q
ATE OF REPORT REGISTER NUMBER