0207-129 (AR)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 forceand effect:•....,,,•
License # Lic. Class 1 v l Exp. Date fop
/ 1
,/4ate �' 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, Busine"ss &p Professionals
Code).
O I am exempt under Section B&P.G:r,fo this reeson
Date �/✓,+�(J 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
S, tion 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 3'fATF,YU14D Policy No. 2�-ba f1C► I4
(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 those provisions.
Date:'// 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.
r,
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions- set •forth eon his
application.
1. Each person upon whose behalf this application -is made & eaEh person at
whose request and for whose benefit work is performed under orpurstiant 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 -representative's of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)'��''�r''"" a, ��- � Date
.r
BUILDING PERMIT PERMIT#
0267-179
DATE f y - VALUATION $20,127,011 LOT TRACT 2f 1
JOB Sl -(E
ADDRESS 273 A3,�6li.C'mSdB.'aM,t.S', �u�,9Aiit,l. APN 770 -M - W7
OWNER CONTRACTOR/DESIGNER/EN (NEER
1ILPEFF.tC11?ROPEIRTeq STN 't7I: "rA D,EV( C:QPMM_, 'i' C0Rr-.
PO BOX V) 44 P) BOX d 144
LA Qi. nsyrA CA 92253 IA. ( fix; :CNTA CA 92253
(160,Y772-2626 CTV� 530
USE OF PERMIT
;x311 ENa.[A T. ADDITION
.A17DITIGN OP 130 Sl OP MASTFM 6A11711.
COM 6°LT.* IRCF W57H ALL PUMAIM, & STATE', I..U3?NO '.)'HE
ESN0A1,4rJ'EP%V13 SPEC:12S ACT OF 'f x'73 (16 t).a.C. � 1531, ET :egg,)
(.9J5T0M CONSTRUCTION 130100 S
'x1.Td1°b7.1) Cl ISIr me C'i)MIZEFC411(oi!F 10,127.00
Pk SUAM"Xy
C;cyNSTRUC'( ION FEE 101000.418.000 %J26.00
PLAN; CHECK ir'1...11101-000-4.39-319 $110.135
ME,(31At3[CAL FEF, X01.000-42'1.000
ZLXC R1GAL ;rG 101-000-420-000
PLUM,91HO PER 101-000-419-000 $4.2,00
GTR."a Nf,3`. IGIN VEX - RE."o113 101-1000-241.000 $1.01
A
TAL 0148TRUC,310W AND P1,A14 CIT .CK
SEP
1I '{fit J , .� 'AL ��"XHA'�4.�.":Z? MN. DTIV, NOW
4��j- vt� ��4G-
CITY OF LA OUINTA
RECEIPT DATEBY DATE FINALED INSPECTOR
W
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 91-9 e_- 57
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 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
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 Notice (Perm)
Cly
° t TqJON TANDY
DEC37630 Medjool Ave.
" l � REC`D
REGISTERED INSPECTOR'S WEEKLY REPORT
Palm Desert, CA 92211
Office (760) 772-7192
`''SFE -Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE O ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑
❑ OTHER
JOB LOCATION
--'�3 6 t n (� �� �� V L
Ir `/•f
REPORT SEQUENCE NO.
TYPE F�R�CTURE
PERMIT NO.
D/>,TE� ' � ��
DAY OF WEEK
MATERIAL DVLEESSSCRIPTION r /�
ARCHITECT
INl•Ug"OR
HRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL SUB
CONTRACTOR N CONTRACTOR I'S
1
CIA
'n S _ Cot x a_ T, �_ CC, L .
1
L CIO I a.�.�, <
'f Oo (A) ek'n ► C Co
utj
I141?_
COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE ❑
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
-...110NING.BUILDING LAWS.
SIGN TURE OF REGIST�EREDD I ECTO//Rliq I t.
,1- a 114_/�7
ATE F R PORT REGISTER NUMBER