0206-037 (RPL)LICENSED CONTRACTOR DECLARATION
..I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section7,000) of Division 3 of the Business and
Professionals Code, and my License is,in full force and effect.
License # Lic. Class Exp. Date
7369210r "IT 112(
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,,,,
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
pe��rfo{rmance of the work for which this permit is issued.
4Y`� 1 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 31ATEFUND Policy No. 15,76409-200J
(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, II sha I rthwith comply wjt Se provisions.
Date: 6 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.
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.
t
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 r6presentatives of this City to enter upon
the above-mentioned propertyfo inspection purposes.
Signature (Owner/Agent) Datei�
BUILDING PERMIT PERMIT#
DATE r; r” f ` ` VALUATION` LOT TRACT
JOB SITE
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L&QU►RPA CA 92253
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USE OF PERMIT
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JUN 10 2091
CITYOFLAQUINTA
FINANCE®EPT.
RECEIPT
DATE. , e `i
BY.' = Tr
DATE FINALED
INSPECTOR GG
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
Steel
POOLS - SPAS
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
Wade Lines
Heater Final
W _ter Piping
Plumbing Final
PI- ;ting Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
_
Gas Piping
Gas Test
Appliances
Final
— l
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:
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A.P.N.: 774-095-016
ADDRESS: 53-325 AVENIDA BERMUDAS
LEGAL: LOT rs BLOCK iZts,
SANTA CARMELITA @ VALE LA OUMTA
CONCRETE
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
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A.P.N.: 774-095-016
ADDRESS: 53-325 AVENIDA BERMUDAS
LEGAL: LOT rs BLOCK iZts,
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CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
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APR 25 '02 14:27 FR
r*1�� Information
/�' .TOBu 1d On
Engine»ng • Consulting • Testing
I TESTED FOR
REPORT OF FIELD COMPACTION
CONTEMPORARY HOMES P
PO BOX 1041
LA QUINTA„ CA 92253
DATE: April 08, 2002
TEST DATA: (1) Medium grained silty sated.
TO 9-5648472 P.01i01
53-325 AVENIDA BERMUDAS
LA QUINTA, CA
OUR REPORT NO.: 073-20089-2
OPT. MOIST. = 10,5%;
.. _—.... ...__.....I ... .._. ...__ ... _. .. ...------•-------•--
�MARIMUM I COMMENTS'
TEST I TEST ; i SOIL ID IAB DRY Yr WATER WET PERCENT Spec. 90� min
NO. DEPTH ELEVATION NUMBER DENSITY CONTENT DENSITY DENSITY COMPACTION
1--- _._..__... --...... I. i _.
FG j 1 127.0 3.6 128.9 124.4 98.0 1 - A
--
...... ......
2 8" FG 1 127.0 l 6.0 125.6 118.5 93.3
3 8" FG I 1 127.0 I 7.2 1130.6; 121.8 95.9
4 S" FG 1 i 127.0 1 8.0 1 '123.61 114.4 90.1
I i i •--
TEST LOCATION: Building pad.
1 South side
12 West side
3 North side
I ;
t4 East side
i
NOTES: TESTS PERFORMED PER ASTM D2922-96 & ASTM 03017-96
DENSITIES SHOWN: Lbs. per cubic foot
WATER CONTENT: P rcent of drY weight
PERCENT COMPACTION; Based on maximum dry
density Obtained on sample indicated by
soil 10 number.
(1) ASTM D-1557, Procedure A
TEST INSTRUMENT:
REMARKS:
TECHNICIAN: Paul Hoersting
'COMMENTS: . t. FILL MATERIAL
2, BA KFILL
3. BA E COURSE
d'SUBBASE
S. SOIL CEMENT
6. OTHER
TIESE TEST RESULTS APPLY ONLY TO THE SPECIFIC LOCATIONS NOTEO'AND MAY NOT REPRESENT ANY OTHER LOCATION6 OR ELEVATIONS,
REPORTS MAY NOT BE REPROOUCED, EXCEPT IN FULL, WITHOUT WRITTCN PEW CCION BY PROFESSIONAL sCRVICE INDVSTRIEe. INC.
1 - A
1 - A
1 - A
A. TEST RESULTS COMPLY WITH SPECIFICATIONS
B. PERCENT COMPACTION DOES NOT COMPLY
c6 RETESSTPOFIPREEVnIOgUgS TEST p
E. MOISTURE BELOW SPECIFICATIONS TIONS
STANDARD COUNT M; D:
ADJUSTMENT DATA M; D:
Respectfully submitted,
Professional Service Industries, Inc.
PSI A-,00-2 r>F Professional Service Industries, Inc, • 42-240 Green Way, Suite C • Palm Desert. CA 92211 • Phone 760/341-5790 • Fax 760/341-5794
** TOTAL PAGE.01 **