0001-234 (SATT)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
ti 74674frr4nr �t'i=: ''+II'.--
Date '% /AG' Signature of Cont
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&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 it 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 carver & policy no. are:
Policy No.
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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 Califorflia -aqd agree Via) if I .should beco
subject to the workers' compensation provisio s of Sect*An 3700 of the, Ca r
Code, I shall fo6hwith comply with.those pro ions"
Date: - Applicant r`
Warning: Failure to secure Workers' Compensation coverage is unlawfulnd,�
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 comp) i."ll City, and State laws relating to the building
construction, and hereby authorj;x,e-reKesentes of this City to enter upon
the above-mentioned property i6r, ihspec( , u os es.
Signature, (Owner/Agent) -Date! ("
BUILDING PERMIT PERMIT #1�i9-t.>`�
DATEy����/ VALUATION S17,1A96(W LOT tai TRACT s?S S
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ADDRESS' F�9 JOB SITE aE�I �3f1' APN
OWNER CONTRACTOR /DESIGNER / ENWNt
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('7;,t)}77i_1g}it CB1.:# 22')96
OF PERMIT
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RECEIPT I DATE
DATE FINALED
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IV).1110
,828.96
11 1 11111 o ill
1 111049
OPERATION
DATE
INSPECTOR
OPERATION
I • DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
40
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Cs
Exhaust Fans
O.K. to Wrap
AOZ.
F.A.U.
Framing
Compressor
Insulation
-
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
- au
Drywall - Int. Lath
Final - -
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
v
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
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)
COMMENT'S:
'
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 )C 4 -PIX
0 POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER ff
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION
w — S/* 0
CAS IA -0, "09- .
r Aj 4-0.
REPORT SEOUENCE NO.
TYPE OFSTRUCTUREPERMIT
cko La Quill
NO.DAT
Cook131
oo
DAY OF WEEK
MATERIAL DESCRIPTION
5 i Saws o><
u eo * cnq
ARCHITECT
INS ECTOR
R 17>.
RS.CHARGED
ENGINEER
&o(A.vi&
ASSISTANTS
.HRS. CHARGED
INSPECTION
DATE
GENERALs � ,
CONTRACTOR
iL F KUB
CoCONTpACTOR
3 0o
0175
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COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE O
PAGE
OF 7
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I 'HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALLOF 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.
IN • f -I 0-t4QASI�
SI NATURE OF REGISTFAED INSPECTOR
3 010 .rc,Bo �/c13Z6- Y�
DAA OF REPORT REGISTER NUMBER