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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provision- 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
Date Signature of Contractor
OWNER -BUILDER DECLARATION
1 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 ex mpt ynder Section B&P.C. f•rt
`his reason'
D"ate L h—;e.f ? " Signature of Owner 1� �.,,f',
WORKER'S COMPENSATION' DECL RATION -
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.
(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 hgll fo with comply with thop
rn rovisions. l'
Date: • 5 > ) 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.
'1 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
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
constructs?n, and hereby authorize representatives of this City to enter upon
the abovelment"oned property fol ingpection urpos�gS.
Signature (�dwner/Agent) r ",' ate
PERMIT #
BUILDING PERMIT ' �V�sE .
p •- VALUATION �,�,p=),/,+,,►',� LOT TRACT
ATE 3 ��r"�'�
_.
JOB SITE _�%S .4� 4 Jsa
APN _
ADDRESS'
OWNER
CONTRACTOR/DESIGNER/EN &NEER
ta,�;�,':� 1�:�1:"�e��<;?:�rE
i�4t�:3:::3.3.-RL'T,�•�.�:iT>��,
USE OF PERMIT
LG+.�d1rtl�:�wi`r�l�
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D,M.L•«+I.d.7. ":J A'4,C1 �.i.,+� iarl.4 *�ry xtrc_a��i fif �. 4•�!n. a.��.� �wz�..rnie t.s_.
VALVIATIOD 10 PI LIR
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$44-25
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RECEIPT
DATE i'
BY �•"
DATE FI ALED
INSPECTOR
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
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Seaver 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:
From: Customer Service 949.492-6295 To: Fax#1.760-777-7011
J
Q 4-1 c?
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Date: 4/15/03 Time: 12:16:16 PM
Page 1 of 1
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
DATE
CONSTR TION
0 By
DATE—Al-:-1 �-o By
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
D REINFORCED CONCRETED RUCT. STEEL ASSEMBLY D C ,1_ /�
O POST TENSIONED CONCRETE ASPHALT D�HER Sib f1�
D REINFORCED MASONRY D FIRE PROOFING U10-161
JOB LOCATION
REPORT SEQUENCE NO.
TYPE OF STRUCTURE ��
PERMIT NO.
DATE /V'.1•/1
DAV Of WEEK
MATERIAL DESCRIPTION
ARCHITECT
INSPECTOR
�1
HRS. CHARGED
ENGINEER
ASSISTANTS
MRS. CHARGED
INSPECTION GENERAL
DATE CONTRACTORcel's P �� fA� cs
SUB
CONTRACTOR
,7
S ���(�S SSU 5
3 .e.� -
. S• i �. X �- X 3
SLS
1-42-0
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE 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.
SIGNATURE OF REGI RED INSPECTOR
DATE OF REPORT REGISTER NUMBER
Certificate of Insulation
-- — Your Horne lyes been ia®ultded WI& COU"Teed pittergteas Irnulatimt products, w" are designed — -- for todaya safety standards and tomos Ws amw roguiwntente.
Fib s V irtorg>!t>ic and lttoe�rn �b�, so it dm not bava 10ie ttadod
--. ---------.--._withfk'"w"A znitandratvr81nalvto aH nveitlMO�-WhurAtbamtreatsd--- --- ----- --
wdb cbemicals that can corrode Wiritg of metal Fiberglas Will not absorb on" me nor will it
`�-------------saytte-axet_�ne_salsa■y_othsx.ineulation-areterials.--- -,--- -- —
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This also certifies &nt CertamTeed Tiber Gkm lasubdot has beep professionally iatalled In this home
In proWde (he Mining &emd performauoa:.
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iva� A+hndat�e .. Trod: 287D Pim ii: 3A PhMW _ 2
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Lot-Wea 47 - Job Address: y9c5t+B-Bs7irStRelr — — ---- -- -
Ceiling Area: R-38 Blown lnsoiatton Garage Celligg; Naar Access-
..: ... . .. . .... .. ..... . ... SII ¢ ..._ .. _ ... . &� 9aping-Asoas .... .
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Exterior Walls: R-13 thd1wed Batts
U* .
OrerDangse Aemm Attu
E -- —
----- — — -----
Wttd Uviug Above
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Interior Wang: R-11 uAfted Batts ��OCo Flosr:
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Sabeombuemir.. Od Ittrsufftafm no, Iwo
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Signed
Tom Berry, Gimffal Mian Wr- TT Q Breath
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R.
means mbtanoo to heat ROW. The higher dye B value, the greater the issnlating power.
Ask, your builder for the fact sheet on R- values. Keep this cerdtieate wilh your outer
valuta papers. 1f you ever sell this lwrm, this ce"cate should be passed on to the buyer.
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