0301-237 (BLCK)LICENSED CONTRACTOR DECLARATION
�d 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
,P�ofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
473 950 5 11 MC C. ! 0 1 1 /111(
Dat`e r'' ' 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.
.V) 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 s'1°.ars. RY•ND - Policy No. - 229-0022.40.02
(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 California, and agree that if I should become
subject to the workers' compensation provisions'of Section 3700 of the Labor
Code, I shall forthwith comply with hose provisions.
Date: j rt'r., i; ; Applicant
Warning: Failure to secure Worlie s' Compens tion 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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
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/Signature (Owner/Agent) r'v.j. �� � ' � ° �`�• Date
PERMIT PERMI001
.. ,BUILDING 217
DATE '. '�. VALUATION LOT TRACT
JOB SITE
ADDRESST 78,41KYWIGINWAY111
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CONTRACTOR / DESIGNER / EN (NEER
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PALM DESa ' T n CA 92211
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USE OF PERMIT
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iVlt�"L".1i) COST C)P' CON11f ROMON
COMMUCTION RRE 101-000-418-000 $231
SUB_T(r,P& CON :'3'1`Ituerl Ykd' a PLW ckMY-,%
LEOS PRE -PAID F' 11.3.
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JAN 16 2003
CITY OF LA QUINTA
R FINANetalpp' / } BYl DATE FINALED INSPECTOR
/ ' Al,
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Seam
Approval to Cover
Equipment Location
t'.
Underground Electric
eI
Underground Plbg. Test
Final i
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
COMMENTS:
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 NotiM(Perm)
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RETAINING WALL SPECIFICATIONS
-- --ALL M'A=LS SMALL BE CONSTRUCTED OF THE 11IGMEST OUALrrY
WORKMANSHIP IN ACCORDANCE WITH THE 19916U.Q.C.. AND THE
FOLLOWING SPECIFICATIONS:
1. CONCRETE . r' e • 2000 PSI AT 28 DAYS MR ASIA Cl SO
2. MASONRY I' Ta 1500 PSI GRADE IN PER ASTM Cl SO
3. GROUT • 2000 PSI AT 28 DAYS PER U.B.C. TABLE 24.6
4. MORTAR • 2000 PSI AT 26 DAYS PER U.B.C. TAOLE 24-A AMB
ASTM C270
S. REINFORCING . DEFORMED BARS CONFORMING TO ASTM. A61 S
GRADE 40. STEEL LAPS SMALL BE 40 BAR DIAMETERS OR MORE.
BEND HORIZONTAL BARS AROUND CORNERS A MINIMUM OF 24'.
VERTICAL STEEL SMALL BE MELD IN PLACE BY VME TIES AT THE
TOP AND BOTTOM OF THE BARS BUT NOT EXCEEDING 9 IT• IN
SPACING PRIOR TO SPACING PRIOR TO GROUTING. STEEL
►LACEMEt4T IS CRITICAL AT THE <A:E OF WALLS AND AT CHANGES
N BLOC[ SIZE. ADHERE STRICTLY TO THE DIMENSIONS SHOWN ON
TME PLANS.
6. -ALL FOOTING TO BE POURED ON UNDISTURBED NATURAL GROUND
OR. ON COMPACTED FILL WTTM A MINIAUM DENSITY OF SM
RELATIVE COMPACTION.
7. DRAINAGE SMALL BE ACCOMPUSMED BY PLACING A 3' DIAMMR
PERFORATED ABS OR PVC DRAIN LINE BEHIND THE WALL AT THE
TOP OF TME FOOTING AND COVER WITH 1 CUBIC FOOT PER LINEAL
FOOT OF 112' PEA GRAVEL. AT LEAST t' OVER THE TOP OF THE
PIPE. EXIT THE DRAIN LINE OUTSIDE THE WALL AT A LOCATION
WHERE THE DISCHARGE OF WATER WILL NOT BE OBSTRUCTED AND
AS APPROVED BY THE BUILDING OFFICIALMAMiTAIN AT LEAST
1% GRADE.
B. PROVIDE VERTICAL EXPANSION JOINTS PER DETAR HEREON SPACE
BETWEEN 60 FT. ANO 200 FT. APART. PLACE EXPANSION JOUST AT
FOOTING STEPS UNLESS NO STEP IS PRESENT.
9. GROUT UFT SMALL NOT EXCEED 6 FT. WHEN GROUTING IS
PERFORMED IN MORE THAN ONE UFT. STOP THE NMRMEOIATE
GROUT LIFT 1.1.2' BELOW THE TOP OF THE BLOCK TO PROVIDE A
KEY FOR THE NEXT LIFT.
10. BACKFILLING SMALL NOT OCCUR UKT4 AT LEAST 14 DAYS AFTER
GROUTING IS COMPLETE.
11. GROUT ALL CELLS SOLID.
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