0001-235 (SATT)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury -that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and -my License is in full force and effect.
License # Lic. Class Exp. Date
W � T��aO��i B r , r31i2(N
� IX
cZ r- vDate ?4 Signature of Contr _or -,
Oti
1= o OWNER -BUILDER DECLARATION
LU a ~ I hereby affirm under penalty of perjury that I am exempt from the Con ractor's
License Law for.the following reason:
Z ( ) 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).
cY) () I am exempt under Section , B&P.C. for this reason
L0.
N Date Signature of Owner
O�
a0)
WORKER'S COMPENSATION DECLARATION.
o cc I hereby affirm under penalty of perjury one of the following declarations:
Lo H O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W 9= compensation, as provided for by Section 3700 of the Labor Code, for the
OJ Q performance. of the work for which this permit is issued.
m Q U I have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued.. My workerscompensation insurance carrier & policy no. are:
� Z
CartierPolicy No.
Cb 5 STATE FON17
� d
QJ (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 Califo , an gre a if I should become
subject to the w rkers' compensatio provlslo pr ect' n 3700 oft bor
Code,1 �a►t fgrChw comply wit7,fhose Prov '6ns:
ate: Or 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, 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 with all City, and State laws relating to the building
construction, and here by-aGfho pesentte of this City to 7�7c,
the above-mentioned'propertyfo ' nspectbrrbu s
ignature (Owner/Agent) Date
PERMIT #
BUILDING PERMIT aftra!3_2.4
DATE A VALUATION LOT TRACT ? 7935
JOB "U'ti?IOL:�.9�i
APN
ADDRESS
649 380 006
OWNER
CONTRACTOR DESIGNER / ENGINEER
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LA t URNCA (::A 92V553
I.1A.QL I[NTA CA 92253
(76011771-1941 (ML11 20961
USE OF PERMIT
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RECEIPT
DATE
BY ' %`
DATE FINALED
INSPECTOR
(
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
t G `
Underground Ducts
Forms & Footings
i GCY
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
- &:r
Exhaust Fans
O.K. to Wrap
Framing
7Gt.T
- 3 W
F.A.U.
Compressor
Insulation
- GQ
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans.& Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
-
Drywall - Int. Lath
Final
Final � cG
BLOCKWALL APPROVALS
PO®LS - SFAS
Steel
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
_ od
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
ewer Lateral
Pool Cover
ewer Connection
Encapsulation
Gas Piping
Gas Test
— 6,
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:
5
�SPECIAL I N'SPECTION SERVICE
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TA►NDY
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
❑POST TENSIONED CONCRETE ❑ASPHALT y
OT
❑ REINFORCEDMASONRY ❑ FIRE PROOFING
1
JOB LOCATION ,,/V - ` S5 0 A As � A "Of-,, � �� 1 N T 4
V
REPORT SEOUENCE NO.
TYPE Of STRUCTUggE
LoT Z ® � Q�ti�
PERMIT NO.
Ooo 1- 235
DATE
3 3 0�
DAY OF WEEK
MATE RIAL.DESCRIPTIONARCHITECT
/ 50A.) cx .ego 47(1S
INSPECTOR
NRS. CHARGED
ENGINEER `
%'6w.V tS
ASSISTANTS
HRS. CHARGED
L Sus
INSPECTION CON TRACTOR "J S Qom{( -S CONTRACTOR
DATE
,31310 o
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3 6,A, -Y-f"'A41 ad W /0 `' VA4tea( e.� y
I i�vl
X i i c000 r-Ae-� ® � /� FAj/Ao-ju .i
COPY SENT TO CLIENT D
CONTINUED ON NEXT PAGE ❑
PAGE 1 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.
' OF REGISTERE .INSPECTOR
3JIGNATURE
04 ;rz ,o /111326^y2
TE OF REPORT REGISTER NUMBER