9809-203 (SFD)X k LICENSED CONTRACTOR DECLARATION''
- Cn I hereby affirm under penalty of perjury that I am licensed under provisions of
F Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
License # . Lic. Class Exp. Date
C�LLJ �/te
ci7i0id i3 r"/3i1
Z�n1 ��iSignaturef ntr for
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J U C:) OWNER -BUILDER DECLARATION
HLLJ rl- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z( ) 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).
cY) () I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner
rn
z
WORKER'S COMPENSATION DECLARATION
C:) CL
Z I hereby affirm under penalty of perjury one of the following declarations:
0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
ED Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carrier Policy No.
o 5 S• ATE --UND 1371095
C3
J
(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 -1 shoUld become
3 subjedto the workers' compensation provisions�of Section 3700 of th a Labor
Wde, I shall forthwith comply with those provisions. l`
e: / c` r, //)114�
� Applicant A
Warning: Failure to secure Workers' Compensation coverage isunlawful 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 representk�tives of t "Is City to enter upon
the above-mentioned property for inspection pui:poses/
r/Signature (Owner/Agent) r Dater' 1 '1` '"
BUILDINGPERMIT PERMIT# CONTROL#
DATE // VALUATION $3.51,31}8.30 LOT R TRACT 28.2 9 4
(� V
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JOB SiTF' t / °s-010 CULLA BR1� A
tt �i 1 y BRAA A
APN �3Y -Z.�i - rliJ
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
T.D. DESI1.111C DEW.11011NIEN'1'
S1't`..RK's CONS,"rRUCIMO1••:
V,0, 130X lilt)
79.295111%NCH0 LA. QU1NIA DR.
LAQU1N1'A CA 92253
CA 9p2253
/L..A�.0,U'}tMgC/r.1.y
r
("BY,# 2099
USE OF PERMIT
SINCYU FAMILY DWILING
W -D, t'LAN .M1, LOT 8, %ERN411' DUES NOT INCLUWI BLOCK W. -UJ, GIS.,
KW)L.Nl,AN C.Ki -W FM 12EDUC11) 75%170k. MIXTWLE I:WJA.M�lg OF
SAML-' PLAN'F'YPE.
Cl.}ST�'1m co i•raucr tCiN 4,213.00 Sir
P0RC.1• ;1A•1 J0 522.1:%0 Sf{
GAR' AUF%(_".ARP()K'1' i 10.00 Sir
1.1«ATi 1.t,VAi ED C(AT OF CON.'l ilt R CTIO v
J9l,muo
PERMIT FEE SUMIMAR
+; ONS'. RUC;1'It319 FEE 101 -WO -418-000 S1.S21,w!I
P1, AN i;'N1;CK FW 10140)-439-31R K1CtR, 7s
NIEG(AN11CAL `37213 41104, 400-14-141,11 Mo S I IG 50
L X'r,WAL FIX- 101 -WO -420-000 $::46.71
Pi.till 81NC7I. EH 101-000-419-000 $205.0
S�'i?t11J("s "AA6 3'P(ftini il:E - �C:.�TI't tiff-fNlfl-'?,[1f .fNi@ R�,S, t4
GIUDI.N110 r1t.l. 101••000, 42!b,000
INFkAS T12 UC f UR[i FF -1 22�000411-312 $ti.00.W
ART IN .-Pili:}LIC PLACES - RES -}r 701-000-255-1300 341.55.47
51,1113 -TCC L CON'S: R(JCn0_N ANY) PLAN t;14EC.K
$9,10105
LESS PRI.-PIUD FE1a:S
$0,00
TOTAL PVRtfflT FFf_*S DUE NOW
$9,102.404
RECEIPT
DATE 1
BY �/ /
1 r
DAI ALED
INSPECTOR
cr , , ..., I v r- . %.� 9 %1 rte
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION,
DATE
INSPECTOR
J BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs / -
Underground Ducts
Forms & Footings L G
Ducts
_
Slab Grade 3
Return Air
Steel
Combustion Air
Roof Deck / G c
Exhaust Fans
_
�' • C �QG
O.K to Wrap _ (,!
F.A.U.
-
FramingCompressor
Insulation - G
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath - 7— 4F,::T Aa?'
Drywall - Int. Lath ,L �• S T
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 .3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral ��
l �
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances l
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
c
t
Final
Utility Notice (Perm)
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 O ASPHALT
❑ REINFORCED MASONRY O FIRE PROOFING
❑
❑ OTHER
108 LO I _ O ( 0 CA(/e n nl CA
LAQutv_.,_A
REPORT SEOUENCE NO.
TVP OF_S�iU�TURE LOT �f
VX
PERMIT NO.
DAA /� /�
(1y`{ IRL
DAV OF WEEK
MATERIAL SCRIPTION
ARCHITECT
I
HRS. CHARGED
F-:- � I T-1
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPESUB
DATE CTION CONTRAGENECTOR eA [-K I.�YIS7r CONTRACTOR�y--
(oIle
1.4
C0006--Tloff
F
XTP TCT p �
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o
Ca ►+1 T
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.
SIGNA URE OF REGISTERED PECTOR
DATE OF REPORT REGISTER NUMBER