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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
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 01'f'ATE. COMP91MATJ Policy No. IW_16168_200
(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. �7
Date: ^+ sE f. Applicant / 7
Warning: Failure to secure Workers' Com pensation'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
of the Labor Code, interest and attorney's fees. n
IMPORTANT Application is hereby made to the Director of Building and S f�
for a permit subject to the conditions and restrictions set forth o i
application.
1. Each person upon whose behalf this application is made & each pers at
whose request and for whose benefit work is performed under or pursua t to
any permit issued as a result of this applicaton agrees to, & shall, indem ify
& 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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) , Date
U cw ! y
PERMIT #
BUILDING PERMIT
03WWWn
DATE VALUATION S✓«'1Sd(.I(y,l LOT TRACT
. i
JOB SITE
ADDRESS 19-'67.? �3.7.�i i►.CJALE COUNT
APN .
OWNER
CONTRACTOR/DESIGNER/EN (NEER
KINi't' I'4.1:� dts A"i�� i �.t�i'� .
C'�i . C't)f 3 � Yci���.� 81'J'UR (MTI MM' CX -Y
1)0B0X 1144
86- 100
xAQITLWrA rA 92233
COACIV,,UA GA. V22?6
(76())98.9222 CM41 00353
USE OF PERMIT
POOL AND/Capt. SPA,
PODUSP,A..AWM IKAIMIERS S'Fit L SZ IN Pl..rtiiCC A.9' 1)X rUP?_AS T?.,R
f N SIT, C';TION, PIOUTPMRINl If EI'aCI.f:MI, ,,i? NOT ) cl,4uDif0.
.7CnAa1-tN.P.xfi:t o y..un OF ciJf.jn—mi4w Ad'k, n
191000.id -
a'.�' HUY011, MAMMARY
. 'IJ CHWIC FU 101-000-4-39-318 S122M
C;tiFl;; s MUCTIGH FE -1r, I GI I.000 -X 19-(Y O $199.00
GIRMA 42a, / FEE -- POOL 101 1100( 421.00 824,40
P.111xi'mC A t L -� POOL l01 $45.00
P.i OMAIN(I FIVE... Pool, 101.000-419.000
FEB 18 2003
►_D. -315 Tkf�l BI-�°I°f, o c:`C9)Tg'mCT(;mov juin Pum, ati�m
x$407 �S
Cts O-
p:PT. i 93 T"T&PAID ITUS1
C1.liG
TOTAL P)WAM3('. FEES UF. NO
40735
RECEIPT
DATEBY
DAT FI LED
INSPECTOR;,kj, y;ii,
4: •.''
0S?.
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
Final
PLUMBING APPROVALS
Underground Electric
Underground Plbg. Test
Gas Piping
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
sz� &-,- -Z 2-������
s, 4 4 "
P.O. BOX 1504
Building 7 O —7i� 3 c'78-495 CALLE TAMPICO
Address / /�C�LA QUINTA, CALIFORNIA 92253
uwne/(i�%�
Mailing a� �
Address �
C' y Zip ITPI.
o9l 7 3/,).293-3
Nuuress
,tom zip T /0 373-� 3
State Lic.7 City �L
& Classif. Lic.
Arch., Engr.,
Designer _44fA1cnw/
city
/Zipgv�� / State �[ �
Lic. # e!5i (/ 7 p/ /7
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5.Business and Professions Code: Any city or county which requires a
permit to construct, after, Improve, demolish, or repair any structure, prior to'fts issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
I: 1, 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I 1 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
17 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
Ihereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
n Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS'COMPENSATIONINSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit Shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of aQplicant Date
Mailing Address
City, State, Zip
Cpl.n 1�)
APPLICATION ONLY
LDING: TYPE'CONST. OCC. GRP.
Number
Legal Description
Project Description
�Mlyfllrl FA 71-010 M-00
Sq. Ft. 3!L No. No. Dw. /sdG
Size 77 Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
stimated Valuation
PERMIT AMOUNT
Plan Chk. Dep. 0 D
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
ZONE:
BY:
Minimum Setback
Distances:
Front Setbackfrom
t Line
Rear Setback fro
ear Pr .Line_
Side Street b
fro Center Line
Side Se ck fro
operty Liner
� 1 -
FINAL DATE
INSPECTOR
Issued by:
at
�' P i00\
Validated by:
\�
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
4
h
Addding
Address
P.O. BOX 1504
r�78-495 CALLE TAMPICO
/ LA QUINTA, CALIFORNIA 92253
U`i' 1)U (A- '�5EAl
Mailing 96
Address
Zi
rlu `i U� NIU p 1��� Tel.
Contractor
Address
State Lic.I
a
City
& Classif.
Lic. #
Arch., Engr.,
Designer
�_ �
.
Estimated Valuation
v
• IState
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of.
Division 3 of the Business and Professions Code, oil that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars (5500).
1? 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If„however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I'1 1, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
17 1 am exempt under Sec. B. & P.C. for this reason ”
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
r7 Copy is filed with the city. 0 Certified copy is hereby furnished.
. CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thip 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. •-
Date owner
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
1 agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above.
mentioned property for inspection purposes.
Signature of applicant —Date—
Mailing
ateMailing Address
City, State, Zip
APPLICATION ONLY
BUILDING: TYPE'CONST. .. OCC. G}P.
A.P. Number 77c) - .`®o —o z-7
Imo 2.. i,r a
Legal Description
Project Description 2-56,11
Sq. Ft.
Size Sto StoriId s !I e
Add ❑ /Alter ❑, _ _Repair ❑ _ _ Demolilion O
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issudd by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
a
Estimated Valuation
v
PERMIT
T�
AMOUNT �^
Plan Chk. Dep.
Plan Chk. Bal.
"� r
Const.,,,
Mech.
- Electrical'
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
4
TOTAL
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE INSPECTOR
Issudd by: Date Permit
Validated by:
Validation:
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
,:rte..
a
BOX 1504 APPLICATION ONLY
Building `t 7LEO
Adress���� v� LA QUINTA,CALIFORNIA 92
253
oW'X W 4 vlwo C^I
Mailin I r BUILDING: TYPE'CONS OCC. GRP. t
Address (� �- 1� �ej A.P. Number V V
City Zip 7e1. 4/'JA I.mob
Legal Description
k.�Ctol,---- I Project Description
LOT Z8
Cly, `� "ii ZIp l2 l �Ot� Tel..
State Lic. City
& Classif. Lic. ff
Arch., E r VV It/"' Com+ 4 ,1 LVLT
Designer �
Address j V ` � � Tel.,—, to!
City / y( U Zip> State
t • 2'Ll Lic. n
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
Ihereby affirm that I am exempt from'the Contractor's License Law for the following
reason: (Sec. 7031.5, Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to Its issuance also
requires the applicant for such permit to file a signed statement, that he is licensed pursuant `to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for thealleged exemption. Any violation of Section 7031.5 by any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
f 11 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I I I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
I l I am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
(7 Copy is filed with the city. O Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT., If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of a0plicant —Date—
Mailing
ateMailing Address
City, State, Zip
Sq. Ft. No. No: Dw.
Size 5`I Stories Units
New, Add ❑ Alter ❑ Repair ❑ Demolition ❑
itimated Valuation'
PERMIT
AMOUNT o
Plan Chk. Dep.
Plan Chk. Bal.
Const. 9�
Mech. /
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
LJ(JO
REMARKS J
ZONE: BY:
Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
Side Street Setback from Center Line �t
Side Setback from Property Line
FINAL DATE INSPECTOR
Issued by: Date •tD_
Validated by:Nov 0 9�n Q
Validation: " I A �, .. ,11i19'
WHITE = FINANCE YELLOW = APPLICANT PINK = BUILDING DIVISION
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under
500 square feet, detached accessory structures (spaces that do not contain facilities for living, sleeping, cooking, eating or sanitation) or -replacement mobile
homes. It has been determined that the above-named owner is exempt from paying school fees at this time due to the following reason:
Add. of Sq. Ft. to New Construction
EXEMPTION NOT APPLICABLE
This certifies that school facility fees imposed pursuant to
Education Code Section 17620 and Government Code 65995 Et Seq.
in the amount of $2.14 X 130 S.F. or $278.20 have been paid for the property listed above and that
building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued.
Fees Paid By CC/ 1 st Bank - Gisela Porter Check No. 63054
Name on the check Telephone
Funding Residential
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Monica Guillen $278.20 $o.00
Payment Recd Over/Under
Signature
NOTICE: Pursuant to Government Code Section 66020(d)(1), this will serve to notify you that the 90 -day approval period in which you may protest the fees or
other payment identified above will begin to run from the date on which the building or installation permit for this project is issued, or from the date on which
those amounts are paid to the District(s) or to another public entity authorized to collect them on the District('s) behalf, whichever is earlier.
J
NOTICE: This Document NOT VALID if Duplicated
Embossed Original - Building Department/Applicant Copy - Applicant/Receipt Copy - Accounting
It :.r
YOUNG ENGINEERING SERVICES
47159 Young Lane Indio, CA 92201 Phone (760) 342-9214 Fax (760) 342-6164
October 27, 2000
Tom Hartung
Building Official
City of La Quinta
RE: Smith Residence, Lot 28 Tract 28470-1, La Ouinta
Dear Tom,
We have reviewed the truss layout and calculations and find it to be in general conformance with the design
intended.
If you have any questions please call.
Sincerely,
Jeffrey B. Young S.E.
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
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑
❑ OTHER �0'Ky
JOB LOCATION a-73 8111aKSle Cr
C4`A;TA
REPORT SEOUENCE NO.
TYPE ORE NLC,pC�o ^��
/YY`
PERMIT NO.
OAT Vv
IN�SPLT�
DAV OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
I
HRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
-DATE
GENERAL�, f t I 1
CONTRACTOR V v
SUB
CONTRACTOR
1 V�
0�g v v �(
G 11
�Q �
W I ('
o^'
019 0)c
tto US C_
COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE O
PAGE
OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF M1%`
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.
GNA URE OF REGISTEREY INSPECTOR
ATE OF1 REPORT REGISTER NUMBER
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
❑ REINFORCED CONCRETE UCT. STEEL ASSEMBLY ❑ -S 00
❑ POST TENSIONED CONCRETE ❑ ASPHALT �THER
❑ REINFORCED MASONRY ❑ FIRE PROOFING Lj, fN G
JOB LOCOOIT
Lh
REPORT SEQUENCE NO.
TYPE 0 S RUCTURE ®�
VLiV
PERMIT NO.
DATk.
OV
DAY OF WEEK
MATERIAL DESCRIPTION-:?
ARCHITECT
I SP i OHRS. CHARGED
�7 SccJ-
�
ENGINEER
pU�
ASSISTANTS HRS. CHARGED
INSPECTION
DATE
GENERAL
CONTRACTOR
SUB (� q_y
CONTRACTOR �J+1
�——uuFs 1c S
w S �T �--
�
Sf C-0
goL)
-71
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 MN
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
1I�
C >f -
S G TUREOF REGISTERED IN ECTOR
011-1 � 6a?-)
DATE OF REPORT REGISTER NUMRFR
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