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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) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class __-! "'�Exp. Date
99
at i. .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).
( ) 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.
(tel 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:
li Carrier S'%ATEFUND Policy No. 1341032-00
f
. Q (This section need not be completed if
��1J ( ) I certify that in the performance c
I shall not employ any person in any
workers' compensation laws of Califf
subject Fo,.the workers' compensatioo6
Code, I shalfor wit comply with the
Applicant (_
e permit valuation is for $100.00 or less).
the worleforwhich this permit is issued,
Zanhe so as to become subject to the
iia, and agree that if I should become
rovisions of Section 3700 of the Labor
Warning: Failure to secure Workers' Co pensation 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. -C
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
correct. I agree to comply %A
construction, and hereby affil.
the above-mentioned proper
�S gnature (Owner/Agent)
ration and state that the above information is
,City and State laws relating to the building
:e representatives of this City to enter pon
inspection purposes.
E Date
BUILDING PERMIT PERMIT#
DATE f VALUATION LOT OWS-444 TRACT
G$15,till:.tfi1 21 21120
JOB SITE
ADDRESS 77-.235 AVERIDA AFi','1x+.,/l.LaA
APN
431471,-1D25
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PAPP O'Y F%O-Ou
FAMMY POOLS C ONSRUC:TION
9000 N BROADWAY LXT
53300 A`r1141DA.WW1
OICLAHOM9A CITY OX 73114
IA Q'U-WTA O'A 92253
(760)564-3653 CDY16 293
USE OF PERMIT
POOL ,A NDIOR SPA r r
PXP,MIT FOR. P00.L f.3NLY..AI.,ARMS/}3ARP.1L1'tS MUST F. X IN PLACEAT
PR&PLASTER INSPECTION
POOL.ANDIOFA SFA l.4C+00,00 LS
GOST OF CO�Tftr'�il�'UC�'H0,11
1',5,0000.00
�y 8�g�.•�+�. �;t ;�r�q��p.y�ypyEi�.900iIATE?
CONSTRUC:klIM4 F12- ,101.000.438.0100 $1.52.00
ELECTRICAL FEV, -• 'POOL x;101-000•,1,20-000
PLUMBING M-- POOL, 101-00019-000 $27.00
F
ip
�
SIM -TOTAL COZ 'T11UC4dX ARD PIA14 CIMCK
�7 X4.00
LESS M. -PAID FEES
$0.00
RECEIPT
DATE r� ,n
BY j/I J
DATE FINALEDSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel i
Set Backs
Electric Bond 1 211,
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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer 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)
COMMENTS:
G
Earth Systems Consultants
�`� Southwest
WN
79-811B Country Club Drive
Bermuda Dunes, CA 9220116
(760) 345-1588 • (800) 9244015'
DAILY REPORT OF INSPECTION OF CONCRETE
SB/R.S CO. GOV. C UBC TITLE 21/24 OTHER
q i
Building Permit No.: DSA Application No.: Date of Inspection:
Project Name: QQ w r \*Ma!Rr&A.i•r�1; "�S .'Ln Z-0 Job No.: 0-70`70 —0(
Project AddressLA Al 0 U �Aa i�-
Architect: l..ti nkStructural Engineer: S
tzpp —
General Contractor: CA _ 1z"n-A Sub Contractor:—" "~�--_
TYPE
ontractor: R�
TYPE OF INSPECTION: ReinforcingPlaceme t
Description of Work Inspected:
Z ,.
^' �1% a zk1p f (tb
— C A .. a.o, 410akr, co.,_,ore_ssac-
Unresolved Items:
Descriptive Location of Samples: t"y &AP-U(Cla
Slump: Cone Temp: Time in Mixer:
% --Supplier: Admixture:
Water Added: Air Temp: Specified Stren" gth: -1— Mix Design: Truck #:
Air Content, %: Unit ; .-:i Sample Time- # of Samples:
Field I.D. Marking:
I hereby certify that I have inspected all of the above reported work, unless otherwise noted, and to the best of my ability I have found this work to comply with the approved
plans, specifications & applicable building laws. Final report issued at project completion.
Inspector's Name/N�:nA,_C,• MiN., Inspector's Signature
All inspections based on a minimum of 4 hours; over 4 hours will be an 8 hour minimum.
In addition, any inspection extending past 12 pm will be an 8 hour minimum.
Contractor's Representative�F�
BD -M-402 (10/98) Copy 1 ESC Lab Copy 2 Project Superintendent t Copy 3 Governing Agency
INSPECTIONS
. JCM Inspections
39725 Garand Lane Suite F
Palm Desert, CA 92211
Phone: 760-345-5554 9 Fax: 760-772-3895
Project ame:
-1r4nc
Project No:
— 90
Date:
_9 q
Project Address: {�
LA -7- S RV '
e ca .n
UBC '-� Title 24 t e
Client:
^ :. O r - ca
LA�
Sub -Contractor:
Weather:
I Su
General Con cto`r:
'SOS. G�O�K Ccn
Architect:
I\rlj \1n cti�C(�� uw.�ir�;
Structural Engineer:
Location of Samples:
Welding Process / Electrodes:
Slump (inches):
Time Sampled:
Time in Mixer: (min.)
Water Added @ Jobsite: (gals.) /'J
Concrete Temperature: (TF)
Ambient Air Temperature: TF
Supplier:
Mix Design: _
— Specified St enr gth: (PSI)
Admixture:
Truck #: Ticket#:
Field I.D. Marking: "
Welders:
-
Unresolved Items: None
See below ❑
Description of Work Inspected: 14
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I hereby certify that I have inspected all of the above reported work, unless otherwise noted, and to the best of my ability I have found this
work to comply with the approved plans, specifications & applicable building laws. Final report issued at project completion. Page Of
Inspector��,1� C„ F!i(� �90
c-, . #� OS 76— g
Contractor's Representative: t
1 P 1,14 G /_ &4,'
opy JCM Inspections Copy 2 Project Superintendent Copy 3 Governing Agency