9809-232 (SFD)O � M
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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
674074 13 �a ii9�S
Da' to %? F ` XL, 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).
( ') 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 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 Policy No.
STA:Ms FaNP 946,11t LI,'�7ITM1073.38
(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.;✓ p
ate,,) l vj Applicant
Warning: Failure to secure Workers' Compensat; pn 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 author,(ze representatives of this City to enter upon
the above-mentioned property for i spectlon purposes. , t
Signature (Owner/Agent) J DateF
BUILDING PERMIT PERM' 9809-232 CONTROL#
DATE VALUATION ��S1ie if,.�{� LOT 30 TRACT 28-,3-16.
JOB SITI
ADDRESS `� 0-055 CALL.0 RRIS
APN
OWNER
CONTRACTOR /DESIGNER/ENGINEER
TD, DESERT LiV4hPM:NIT
SPAR'vS6ONS4iUU^af N
€',O. SOX 17.16
70-295 RANCHO LA QUINTA 111.
LA QJIVI M CA 92:253
LA. QU1NLF1'A. CA 9275:
(7(50))771-1941 CBL# 7996
USE OF PERMIT
SINGLE FAIMILY'DWELLING
SFD,`t%LAid Nil, Laf 30. PERMIT DOES NOT 1140A.UDE;LLOC1s WALL OR
POOL PLAN CHXK rEER&DV.FD 7Sa✓o FOR tilt;7MPLE ISSUANCEOF
SAM PLAN TYPE.
CUSTON't CONISTRLCTiON, 4.Z43,00.SF
PO1dC%iik'A'T1C7 Sa2.Ctt1 SI'
GARa4.CP 9CA PORT 710.00 i
STIMAT' D COST OF CONISTRUC710IN
351131" ;9)
PC1iNO"li FEril Sl .r%0Ct Y
C 0N3` T<U(, P:10N FEW 101-0011-418-000 $1.521..50
PL.iA,N("i.1 C1c FEE !W-fiiN?-419_:11�s ��1R.:•'3
MECHANICAL FEE 101-000- 421-0 O Si3t3.�tl
l:` EC'kPJCA7_VMw .101 -W -420 -Ml S.246,71
1?1,t71� 1i�fcli 101-doo-419.00107 $21100
8Tk0N0 M0Yr[0N FPM . R0,40 101.-000-24140 $35.14
0RADI?4O VIED 101-000423-000
IN1,Ti, AS' f' UC>'1't7l' E rfiL 22 -41X1-443-342 K000.00
ARP IN PbfRUC PLAGTGS - RESU-4 701-M1-255-000 S6214A7
SUB -TOTAL CONMUCI ION ANY), ALAN C`.1-tFCK
S% 102.()5
LESS, PRE -PAID FEES
$O.f)f)
T'LlTia , PERMIT F7f EN .1 Uit, iVO•Y
y7,*oum's
REC PT L�
DATE,rBY
DATE FINALE D
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
—, G� d L-
'L�
Underground Ducts
Forms & Footings
r'` (
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
,L
Exhaust Fans
0. 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 i
Water Piping
Plumbing Final,
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
—G
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
L�
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 O STRUCT. STEEL ASSEMBLY
O POST TENSIONED CONCRETE O ASPHALT
_❑. REINFORCED. MASONRY O FIRE PROOFING
❑
O OTHER
JOB LOC I t _ �� � n ^ ^ _ � A OkiKJ\_ h�s�.J
•V
REPORT SEQUENCE N0.
TYPE OF S;5TURE ^
® V
PERMIT NO.R _
DV, 1 1
DAY OF WEEK
MATERIAL DESCRIPTION�`��
ARCHITECT
I SPECT R
NRS. CHARGED
'
ENGINEER
ASSISTANTS
NRS. CHARGED
INSPECTION
DATE
GENERAL^ Q I SUB
CONTRACTOR ly 1F�K CONTRACTOR
`t
PI
60 N N eC'T-( c3 N (9-7'ES L
e co
ori
COPY SENT TO CLIENT
ONTINUED ON NEXT PAGE O
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.
SIGN TURE OF REG RED INSPECTOR
17
AT F REPOAT REGISTER NUMBER