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61
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
Date 7 J j Signature of Contracto /
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Cont ctor'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&RC. 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.
( ) 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 Policy No.
el 14. I J M!
(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 which1his permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Califon
n,J'a d agree that if I sho ecome
subject to the orkers' compensation ,' Ions of Section the Labor
Code I I rthwith comply with. oseArisions.
Date:! , 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.
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 -a thbrize repr ntatives of this City to enter up n
the above-mentioned props for i ectio pu
Signature (Owner/Ag tr -�
Date
BUILDING PERMIT PERMITt
tJCItD 0-1.41
DATE? / J�W VALUATION S171196-60 LOT !or? TRACT < 71� ��.
JOB
APN -
ADDRESS649
390 006
OWNER
CONTRACTOR! DESIGNER/ ENGINEER
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LA i,,JU11-4•!•A (,'A +2153
l.Ai•AlINTA CA. 91),.E�
17c%V07I",1U41 t `tAJ_n 21rikh
USE OF PERMIT
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RECEIPT
DATE
DATE FINALED
INSPECTOR
INSPE�TI� N �ECrJRCJ
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
t
Underground Ducts
Forms S Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Z/ GAJ
Exhaust Fans
O.K. to Wrap
- - GcT
F.A.U.
Framing
—
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Farts & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
-ccj �-
Final _ caJ
BLOCKWALL APPROVALS
Steel
POOLS _ SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBIND APPROVALS
Gas Test
Electric Final
Waste Lines
_ Q3 1&tAt
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
�ewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) 1 5
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) C7r%
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
INSPECTION
PERFORMED
-
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY 4�pox
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
O REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION T1�_i -I Y - 5 Zo L' Rsr r I
�q 6kr�
REPORT SEQUENCE N0.
TYPE Of STRUCTy�RE
5F Lo 6 y 0l�tti+c �o a Quiff
PERMIT N0:
000 (� Z3 7
DAT Q�
3 3
DAY OF WEEK
MATE RIAL.DESCRIPTIONARCHITECT
SD IJ O. ZGIjD 0 Lo45
INS ECTOR
It j b,
'MRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL/
CONTRACTORTD �e� IBJ. s
I SUB -r,-
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COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE
/ OF /
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL QF -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 REGISTEF6p INSPECTOR.
,:> a;lr�o /tft 3ZA, -VP
IF DAFrE OF REPORT REGISTER NUMBER