AR (0303-105)M
•fl' LICENSED CONTRACTOR DECLARATION
4. 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
'NProfessionals Code, and my License is in full force and effect.
'License # Lic. Class e E-xp, Date
67.10" 19lffcC, `'� �'7/31--10:3
Date ``���a,!0/�cj+/` Signature of Contractor• _�.� `�,
_T 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.
Jp ,)° 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 STATE FUND Policy No. 046-7338-2003
(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 Californland agree that if I should become
subject to the/workers' compensation provisions, of 'Section 37001of the Labor
Code, I shall forthwith comply with those propsi s.
6Date: ,> C!% 7'0-1/APPlicant
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.
' 4
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.
ii
I certify that I have read this application and state that the above information is
correct. I agree to comply, with�all City, and -Stat laws relating to the building;
construction, and hereby authorize representatives of this City to enter upon'
the above-mentioned property for inspection purposes.
K110
Signature (Owner/Agent) `— Date 4
BUILDING PERMIT PERMIT /f
_
DATE VALUATION &M, 768;W LOT 48 TRACT 292183JOB
SITE
ADDRESS '19-3221��►'�.510N DP.II, ,
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
'M IMERT DEW -L PMENT
F-PARICS 00MVkUCrfl_)1sT
PO f30X 1716
'19-295 RAWHO LAs. Q1:WALM,
LA, QITU47.CA i',,.i1 952253
LkQT-A1:61"fA CA 92253
(760)771M1941 MA 2996'
USE OF PERMIT
'REMENMA - A1;IM 1014
PPL. 1A.i1 AL TU FXKMAJ a6. ,HJLnr11T E►LiiJ h9tj 4 /6 ZI WY: rr L.tiNla
GT.1MT a DURING 1141TIA1,WNSTR.'750/o PLAN 0.190 K R DCTCTIOAT FOR
$3bTT,T1P1.P ISSUANCY Ci? SAME PLAN `1` P&
CUSTOM CONS'TRUCTIO14 47101 SP
ES i1•ATKD COST OF C' �OWaS'YRUC'I'TC7N
1"3f RAM FEE SC1I'u 'df IRY
COWSTRUCTILi2 FEE 101-000-418-000
PLAN CHWX IFFE 101-000.439.318 Sd7.2i3
I
MECHM1C.A.L FEE 101.000-421.000 $39.30
19=X ' WAL FEE 101-0100-420-000 $31.52
PLitWNG1''T?E '101«000-419-000 .. $60,00
STRONG MOTJON FEE -'M9111 101-OQO-2 41 • DS1(1 $3.68
ART W PUBLIC PIAM - REME 270-000.445.000 $91.92
1:
XW RITCn_0X A11413 PLAM"*+1" c,IIL�`�:,
IMS ;E3%% -PIM FMS
�Ci23:8f1
$0100
�O pd3 T�1J PERM. FEES Dft now
4
p ..
CF EDEA
.- .'
RECEIPT
ATE-
BY t
DATE FI EO,/ ` 4
INSPECTOR G
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
— DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
—3
Return Air
SteelCombustion
r
Air
Roof Deck
�o — 6 -
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
—
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
/ 4
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
in Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines_
_ — r
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
oo^
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
2 —
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) `14
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:
ISP'ECIAL INSPECTION SERVICE
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
78-194 Elenbrook Ct.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF kLA 6
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE CISTRUCT. STEEL ASSEMBLY toll
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION � � � � ,{�/�� „ � S 0. v;
J
REPORT SEQUENCE N0.
TY E OF STRUCTURE e,�,I
i= ® o Ks� � 1,
PERMIT
QUAN
DAT
11 'o
DAY OF WEEK
/'
M DESCRIPTIONJARCHITECT
INSF%ECTORt
HR5. CHARGED',�ARIAL
9IENGINEER
ASSISTANTS
NRS. CHARGED
INSPECTION GENERAL SUB
DATE CONTRACTOR S 0 CONTRACTOR,
Z
Li S
2n Z, Som ZZ ox �'ollO�S
VAT T ® or
I�i'JS� ac.,J cin
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
'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.
AT RE OF RE61STERED INSPECTOR
X Z 03 lcA6 (s -o -r7 Z f7
DAA OF REPORT REGISTER NUMBER
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,- Certificate of Occupancy
I.caeroanTm�
wss
G
OF Building & Safety Department
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS:79-322 MISSION DR. WEST.
Use classification: S.F.D. Building Permit No.: 0303-105.
Occupancy Group: R-3 Type of Construction: V-N
Owner of Building TD DESERT DEVELOPMENT AddressPO BOX 1716
City, ST, ZIP: LA QUINTA CA 92253
By: G SHOWALTER
Date: 05/14/04
Building Official
POST IN A CONSPICUOUS PLACE
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