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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
0-10774
.107 is 7i3i/v9
Bat gt "' a ' �7�' Si nature of Contractor
OWNER -BUILDER DECLARATION/ 1
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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, Business & Professionals Code).
( ) 1, 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 Siqnature 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.
(�d 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 agree that,•if-hshould become
suPje'ct to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisiohi .
./Date: '^,`t. �i'F Applicant—
Warning:
pplicant Warning: Failure to secure Worke(`s' 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 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 r prese,�atives of this City to enter upon
thea ove-mentioned property forgin§pection purposes.
,
r- Ignature (Owner/Agent)
`V
BUILDING PERMIT PERMITWYO 167 CONTROL#
DATE VALUATION S2641,917.211 LOT 4 TRACT 18-290
``(
JOB SITE 9-976 CAULV `� � i;RiSA
ADDRESS ....r•
APN
649-216-063216.063 f
OWNER
CONTRACTOR/DESIGNER/ENGINEER
1r 1`DEV1.3LOM"MINIT
sT),vwScCNS'iTuJcP'ON,
P.0. BOX 1716
79-295 RANCHO LA Qi111V" 1'A DIC
1.,t1 QUiiTPA CA x'2253
LA QU[N-1'A CA 97253
j'70))771-1941 C R-1111 29%
USE OF PERMIT
SINGLF 1-AMILY DWELLING
SFD, ULAN MI, LOT 4, PERM(T DOES NOT INCLUDE BLOCK WALL OR
POOL. PLAN ME K IFFY 111 A)CLM 750.b FOR IVIUL'.l IPL:E ►:.10JANCI, CA,'
SAME KLAN ME.
e;0 -131 r O&I CONSTRut MON 3,076.00 S
N'012t nIIATIO :.580.04 6
UARAG19CA 3CORT ti33.0(1 S1
1",3 fl1liINME D CUST OF i..'+.iNSIARaUIC11aONT
260,91 7.20
PERMIT FEW. SUMMARY
coNsrRu rION PT -4 101 -M -419 -WO SN,a)3 C.u-I
P1,A,1v CHF.( is FtHF if1{-()M.43Q_118 - 1r47:f)?
&413t r 3ANICAL FUM '101 _000-421 1-000 $12419)
Ct.E;tu Pltic Af. RE E 1('ri-000-4.20-0(10 310g.52
1+1 ClM1 I Afi# .N LiN 10.1 -000419 --ow S LV IXT
"•'4°r3<?Nits CY7't4i'n11"F�� 01"Nin i,I?1-L1M-2..4I^X) $76,09
ORA\DNNG FEE- 101-000- 323-000 1-110.00
1N.1*14,r',N'C1fiilQT4)R,:HI1F; 225,GW-113-342 S5,697,117
t1RT 1N PUJ3Ltk.: Pi,A(:I::E - RE 3111 701-OW-25541I'i4
�qUB-"1Y,)TAI,COW4'i?t. (_71I ,)N AND PLAN C 141.0
,t8,lr)IR, O:i
LESS t'IZE-11.11t101TE
".00
TOfAt,I°i�RNII!TiFEMf 44',NOW
U.108,04
RECEIPTDATE
BY '
D TE F ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings Lel
Ducts
_
Slab Grade (
Return Air
Steel
Combustion Air
_
Roof Deck
Exhaust Fans
O.K. to Wrap 2
F.A.U.
Framing `
Compressor
L
Insulation z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath .
Final
L l�
Final 7T70 r, Ci.
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 5
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral ��`�
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
4
Final -l6 rk
Utility Notice (Gas) Z Le—q-0
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) L��
JON TANDY
37630 Medjool Ave.
APB `P rn " Desert, CA 92211
Office (760) 772-7192
• Fax (760) 772-7193
Pager (760) 776-3338
REGISTERED INSPECTOR'S WEEKLY REPORT
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑
❑ OTHER
JOB LOC _o Cf� �. le'��
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REPORT SEQUENCE NO
OF U�TURE Lc)7,* �
JJSVVC\\RIPTION
PERMIT NO
DATE' 1
DAY OF WEEK
MATERIAL
ARCHITECT
I1^- WR
HRS. CHARGED
FENGINEER
ASSISTANTS I
HRS CHARGED
DATE INSPECTION CO TRACTOR S PA e KS C-41MENEL CONTRACTOR
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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
GOVERNING BUILDING LAWS
GNATURE OF REGISTERED PECTOR
4- '07q�
C-6 0 L3L-1
DA E OF REPORT REGISTER NUMBER