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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) ot'Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp., Date
74
V15 -ate ��, �%< ] Signature of Contractor!
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).
O I am exempt under Section B&Rd..,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-fof which this permit is issued.
t� 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:
CarrierPolicy. No.
v`i• .�.r ., ro,r, 0 -
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(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 Califom and agree that if I uld become
subject to the workers' compensation'prr islons of Secti 70 of the Labor
Coder I sh I fo hwith comply with•tho provisions..
\DetB:"7'C c� Applicant '
Warning: Failure to secure Workers' Compe sat'ion coverage is unlawF I and
shall subject an employer to criminal pen i les and civil fines up to $100,1000, 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, indemnity
& 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 .wi all City, and State laws relating to the building
construction, and hereby auth ize representatives of this City to enter upon
the `ve-mentioned proper7fAr 'z�sp�ctiop rposes.
ignature (Owner/Agtsm)-� y Date
PERMIT #
BUILDING
VALUATION �PERMIT �4W0,11-4w
DATE oT t,5 TRACT
G i 1
JOB
ADDRESS
APN -
OWNER
CONTRACTOR / DESIGNER I ENM14WM JOU
•Iyl i^`, 1: K; 37'r' CSS G !' Z A f'f��
i•n L 47;.t f-' N!r U I rf cfe•, S
PC, BUX i'ii6
79-29? RA:NCHO ia.AQ!U'i1vrA Tali.
LA QtW. I'f'El CA 92 5,3
LA QUIX I'A CIA 922:K1
USE OF PERMIT
Slt` GLY " AMILY DWELL.,.),NG
:;f t� i �_;%v:� Fri.•r�id -i i rt: iii f+OE-.', i,;('J j INCLULi) . i{i-00 WAiA1, OR
t+i hit, ?:,`.'-'n 4)I,Aiti �:Hi�L.�K. I•'E�f;. I(Y:I.i1S(: i'.t(.)N 1•'(7}?. Ml!'L.'1'!i'l.l� 1�SStJA:di';1�, i,)i• .
"ANIS PL Ate' ' I A'PE
41.x.}1r.JlY1 `.�l: a'9J/ItiUI<-r1L�+�+ 2,0,7in 41011F
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MST 10"' 'r XTIS IRI I `MI V'V'1„
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t i LA','NUCAL FEE i 41-000-420-000
VIAL! IBIN0 FEE* IU1-(lilt)-�1°d URS 511f�1.h
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ACI -IN F"iJtMJ(.' KA(148 - }{(?;.z}U 701-0UO-2 x-000 ` 11012 .+,J
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I FSSa Pr' E PAID
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1'0YA1, P11,9011'a' 00 V, N(AV
RECEIPT
DATE
87";. ,
DATE FINALED
INSPECTOR
�..i`
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backst9jUnderground
Ducts
Forms & Footings
tsek.
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
u/
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
d
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall insulation
Condensate.Lines
Party Wall Firewall
Exterior Lath
— d
Drywall - Int. Lath
Final
Qom- d Ef
Final
BLOCKYVALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main 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
—GP/
Heater Final
Water Piping
vPlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
' Sewer Lateral
„JA
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
QZ)
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)
COMMENTS:
Z
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
INSPECTION
PERFORMED
O REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY oxv
❑, POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION w_ S-00CA 6 / Die. � ^ LA
•L�'l t � 4<k
REPORT SEQUENCE N0.
TYPE OFSTRUCTURE7
sF Lol * (oS @ o L.a Qliw
PERMIT NO.DAT
G oo - Z 38
1%- '1oa
DAY OF WEEK
MATERIAL DESCRIPTION 0 �G� y945
5 '1
ARCHITECT
IyS ,CTO
HRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
qENERAL CONTRACTOR eT f aeKS IOA+�ONTRACSUBTOR
F.A W� 1
3 3
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IF
COPY SENT TO CLIENT ❑
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.
SIGNATURE OF REGISTE INSPECTOR
3 O d sc-ew 11113Zk —`i 7
ATE OF REPORT REGISTER NUMBER