0401-411 (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 force and effect.
License # Lic. Class Exp. Date
691405 B me OW01/2(
Date�Ld_4) 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 ownef 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 of
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 3TATR FUND Policy No. 04$-6570.2003
(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 shal�� I f h comply withahose proyl lons.�
Date'^ Applicant1 �r P,a"dd.�(r►d�
Warning: Failure to secure W k rs' 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.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or purs
any permit issued as a result of this applicaton agrees to, & shall, in ify
& hold harmless the City of La Quinta, its officers, agents and empl 0 .
2. Any permit issued as a result of this application becomes null and ' if
work is not commenced within 180 days from date of issuance o u h
permit, or cessation of work for 180 days will subject permit to cance i
I certify that I have read this application and state that the above inform ion
correct. I agree to comply with all City, and State laws relating to the b ilding
construction, and hereby authorize representatives of this City to ente
the above-mentioned property for inspection purposes.
Signature (Owner/Agerit);Dat-
BUILDING PERMIT PERMIT#
DATEVALUATION LOT 62� A TRACT
=1,504.10 3 26524
JOB SITE APN
ADDRESS ",9.40)."IUA 4.%Y001) 769-160-€04
OWNER CONTRACTOR/DESIGNER/EN (NEER
1 RUE D.EAVt7VR1Le --' 45.TY 0 CLIJB Mi E
NEWPORT PIF -A .9.. CA. 92660 DMIAN Vitt I T. S CA 92210
>lr'60)772.1011 C 1.1 4999
USE OF PERMIT
KE20MIn'A AD013'1C1X
3137S'P AM1j'7ITMON PER APP.RO'V2D PLANS. 2001 CUC,
TRACT CONSTRUCTION .337,00 SF
C# .R AI;'aEfC.AAPORT 25.00 af+'
E.V17i1!@'All r.O 0045 T' S_ r" C0.Ci'i�'''MUC'110N
F'MOT FEA SUMMARY
CONSTRUCTION FEF:
101.E 00.419.000
$125.00
PLAN CHECK 17CF,
101-00C-419-31 S
$1 16.0
MECHANICA1, :F EM
101.000-421.000
G. 00
ELECTRICAL FE -E
10 t -000-420-000
$48.55
Pilum-BTwd11`I~E
101.1'10:1-419-000
$22150
STIZO24C3 MWOTION FEE • XF-SII}
101,000-241-000
$2.35
S Q -TOTAL CONSIS :U(MION AYID >+'Z..PX CHC(17, $S 18.09
LE4133 11RAE-PAID FEW $0.00
TOTAL PERIVEt MS MV. -NOW IS. 0.9
122004
OF LAQUINTA
RECEIPT I-)
/,? G i , I BYE % /I DATE FINALED ' I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
J
Underground Ducts
Forms & Footings
Y -
Ducts
Slab Grade
Return Air
Steel
16
Combustion Air
Roof Deck
- -
Exhaust Fans
O.K to Wrap
—
F.A.U.
Framing
y
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
- f/
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
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:,%
1<
A
x
s�. City of La Quinta
177-q8o('A'" U16014uilding & Safety Division
P.O. Box 1504, 78-495 Calle Tampico
Permit # La Quinta, CA 92253 - (760) 777-7012
D0%7� Building Permit Application and Tracking Sheet
Project Address: 1_07-.3 -rllE ES%AN / Owner's Name: R08Ex T eA-t
A. P. Number:
Address: rRU`C' 2)6hV V/ LLE
Leeal Description:3 7 Z
City, ST, Zip: A)6 P0A7 qbEAC/f
p
Contractor: C-AAgsl G ul L b e - P-5 /IV G ,
FTelephone:
Address: _ &o497L yl4
Project Description: N
City, ST, Zip: v
Telephone: _
State Lic. # : r City Lic. #:
Arch., Engr., Designer. (,i ALL# I'M -M. CAECUM LTD
Address: LIS -t 9 0 Ci -v13
City, ST, Zip:
Telephone:
State Lic. #:/-•' _
Construction Type: Occupancy:
Project type (circle one): New Add'n Alter Repair Demo
Name of Contact Person: 2AVI D -!FR -TdK
L
q. Ft.:
# Stories:
# Units:
Telephone # of Contact Person: - ( 9 3
kstimatedValue of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
?i
Plan Sets
Plan Check submitted
Item
Amount
y
Structural CAM
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Energy Calm
Plans picked up
Construction
Flood plain plan
Plans resubmitted
h1 thanical
Grading plan
2'' Review, ready for co ecti s<
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"4 Review, ready for correctionsrML
j1
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
=��-76 OU)? /Ve(k ��Y/oy
�9
f BY• S+rue- - b&cX A ppe'oua.lole- wle.or/'ee-izm�cs
SPECIAL INSPECTION SERVICE
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
78-194 Elenbrook Ct.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE O STRUCT. STEEL ASSEMBLY
O POST TENSIONED CONCRETE O ASPHALTO
O REINFORCED MASONRY ❑ FIRE PROOFING
❑
ER a K
JOB LOCATION
v („{1
REPORT SEOUENCENO,
TYPE Of E q L ^-q�
i^t l'IA\/
PERMIT NO. ' _
DAA
DAY OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
IN:B•LPJ ORS
MRS. CHARGED
'b�
/'
ENGINEER � � � `•.n
" V
ASSISTANTS
MRS. CHARGED
INSPECTION
DATE
GENERALn r SUB
'CONTRACTOR jo AV V � La"'t S6v'-'-- CONTRACTOR
3
0.8L5&-.CkFlw .S
0 o L�
COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE 31
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.
G gTUR OF REGISTER NSPECTQRC0
DATE bF REIPORT REGISTER NUMBER