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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
Date 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
cYimpensation, 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&C. for this r
t_�eason
Date r Signature of Owner i4 ' A1
WORKER'S COMPENSATION DEQ A ATIO
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 4ree that if I should become
.e
subject to the workers' compensai. tion provie'ons'�of Section 3700 of the Labor
Code, I shall forthwith comply with',th�ose pro,�'sions�
Date: Applicant A A -
Warning: Failure to secure Workers' Compensation�L,ccc�o,verage is unlawful and
shall subject an employer to criminal penalties and civiffines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to complywith all City, anState laws relating to the building
construction, and hereby authorize repres ntatives of this City to enter upon
the above-mentioned property for inspection�purposes.
gnature (Owner/Agent) ��� 1 r� Dates
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i PERMIT # "
BUILDING PERMIT�R.t.
DATE VALUATION "'I,-.��� LOT TRACT
JOB SITE
ADDRESS "2$� � �LI�iY2�iT j.e LSF .
APN
W4401 106
OWNER
CONTRACTOR/DESIGNER/EN (NEER
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1A QSTUNTA
USE OF PERMIT
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tMARY
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Mfe.C11,AA IC.N, 71M 100 X10100.1121 _000
Y_1 ZC TRICA1., P+20 $2177
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RECEIPT
DATE r f
BY
D E FI p�
IN
ECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 't
Ducts
Slab Grade 4Return
Air
Steel 10
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
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
Fixtures01
Main Service
Sub Panels
,Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
r, F. `ti.Lxi+,�,c;Yr.a.(4'v•-w�•.y.., .l,a-+r,��,.�.,�,.1- 'Ja;a::. `.t%}itiis4�,..•.sf;r I,y+.,,'I`.-',hw�.wr'b:,.vrrro;r�'y"•.ac.�'^/S4..r.v`�.,rYc..:..,j1
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
INSPECTIONFax (760) 772-7193
REGISTERED INSPECTOR'S WEEKLY REPORT Pa9er (760) 776-3338
TYPE OF y
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY �❑
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑TOTHER
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOBLOCATIO� f/ rq� �� �� / ��,v\�
11[[((��E CCZl/r e y� /)
(^PERMIT
REPORTSEOUENCENO.
IV/`
TVPE,OF SjRUC
N(O.~
DAjE ' ? /
DAV OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
wSSPPE-1102•—r
HRS. CHARGED
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ENGINEER
ASSISTANTS
HRS. CHARGED
r
INSPECTION GENERAL SUB
DATE CONTRACTOR CONTRACTOR
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COPY SENT TO CLIENT ❑
CONTINUED�Q� NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV
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.
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SIGNATURE OF REGISTERED INSPECTOR
)SIGNATURE
()3 Tz� 0 6(4-)q
DATE OF REPORT REGISTER NUMRFR