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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter,9 (co�:ncing 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
446180 C291ZC
Date !" 4 r l Signature of Contractor % ' ~'/ r✓
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.
( ) 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. 52647643
(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 Sectionf3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: /_ le 6 '2 If Applicant l / ` V..-
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.
1 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 inspectiop.purposes.,
Signature (Owner/Agent) �f "i Date ( `�
BUILDING PERMIT
PERMIT#
DATE V V"LUATION LOT
MI1-230 TRACT
' 3 r S2�fi4€1.0�►
21 27728
JOB SITE
APN
ADDRESS ,2 fU41ci• 4r+e.,D D UVEr
OWNER
CONTRACTOR / DESIGNER / EN INEER
JAMM 4 LORI F'IUWEN
JOHM )3"AJ&44 44 AMSONRY
PFI MUD.R.D014RS CA V2201
(760)'445"3912 Cf1141 11601
USE OF PERMIT
1-YU tAL"CUILUR40
ADDITIM' Off 2" Vo LrA15TING 13'I,OCK WA141L I>EK KNOINIZE 2ED CAW -01.
4 Ir'i'. VIAL1,
115: .10 1Y
:EXIINUTED COSU OV C;ONS`''"ETUXUTON
PERMT.r ii'1±.'�+' b''U.bnMA:l Y
P"M cf jwK -M '1101-000-4,39-318 $35.10
t'.Cr ;S eRCIL I'1C52J MtZ 101-0(1
()-1 18-00+1 $54,00
D L1_D
I
JAN 2 8 2004
CITY Of- L.t QUINTA
FINAiICE DEPT.
3W'.',.T0TA1_ C"ONIOnTtIX!f10rTAND k'I.t N MIRCK
}:X*33 PRE-PA(T) i?R.U3
TirM111IRIV'MU IriMS 017E NOW
DATE cj/
DATE FINALEDI INSPECTOR
4
7 — /_ACZ
$89, i 0
$0100
91.10
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Sriab 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 V
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
oe
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP OVALS
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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
JCM Inspections
39725 Garand Lane Suite F
LT.1%JPalm Desert, CA 92211
INSPECTIONS Phone: 760-345-5554 - Fax: 760-772-3895
ah
INSPECTIONS
EPDXY INSPECTION REPORT
Date:
Project Name: 'Q Project No:
Qw
Project Address: n IIty: 1 ^
le 24 AWSUBC
File # D 1.1
App# ❑ D 1.4
Other
Other:
Client: Sub -Contractor:
n.1.1n � �)r7.t a
�General Contractor: 1 Architect: (� Structural Engineer: p
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❑ Anchor Bolts ® Rebar
Epoxy Type: ..r � D'.,7 , �� l n � R 1 + E. �^� '
Epoxy Shelf Life:
(
Hole Cleaning Method(s): ir n n 41', + (e-' -n.2 C r _ , - 1�� _ r c f C �� t a
+
Weather:
Unresolved
_+s:
..None
See Below
Description of Work Inspected: C --', r,,c ,, 1` ^��� — , �' ��1 t L i(\ r \'ti t n •� ' re.? c
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Work complies with written approval from Structural Engineer and ICBO Evaluation Report #
1 hereby certify that I have inspected all of the above 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: =r%. JA, C. , Mnn: t r,t ; y ��� 6'
c ontractor's Representative:
Copy 1 JCM Inspections Copy 2 Project Superintendent Copy 3 Governing Agency Page! of
L"t.
JCM Inspections
.1%J 39725 Garand Lane Suite F
Palm Desert, CA 92211
INSPECTIONS Phone: 760-345-5554 - Fax: 760-772-3895
To
INSPECTIONS
STRUCTURIAL MASONRY INSPECTION tREPORT Date:_ _
Project Name: 1. t
r6awQ a s � r� e ., �o� - �- a� 4 u4 r r
Project No:
G3 - Sao
Project Address: (� City: `
s <1:O q.. , ` � "—\C • `lt� �`
Title 24
File #
App#
AWS UB Other:
E]D 1.1
E] D 1.4
0 Other
Client: Sub -Contractor:
-+�-
� ✓ �� t 0 i 4 n c
Geen�eral Contractor: Architect{: Structural Engineer:
t�ttAA"Sp (O ^�h V�: N �`5ot� �►.Jis i�c� S�t�r n�. ednS+►�1T��
n
Slump (inches): �,,�. Supplier:O { C,> 14-,,.
Time Sampled: Mix Design V4
�
Time in Mixer (min.): M�y Specified Strength (PSI): 14
Water Added @ Jobsite (gals.): , r��n�+ � Addmixture:
Concrete Temperature (F): Truck #: Ticket #: `'�•
Ambient Air Temperature (F): Field ID Marking:
Bather:
sane
Unreso Items:
.None
❑ See Below
Location of Sample:
No Samples Taken
Description of Work Inspected: �„
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I hereby certify that I have inspected all of the above work, unless otherwise noted, and to the best of my abili I u
plans, specifications applicable building laws. Final report issued at project completion.
i ork to comply with the approved
Inspector: Jac C. Millin ICBO rt' i a ' n No: 0842216-82
Contractor's Re. e e t
Copy 1 JCM Inspections
Copy 2 Project Superintendent Co�YYGoverning Agency Page J_ of