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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 -E, E771i;V99
67,40 i B / ) Z
ate 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:
( ) 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 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.
°Ti�T+3 i`bie ii 04 -JS UNI"'IM733S
(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
workerrs' compensation laws of California, and agree that if`1 should become
.subject to the workers' compensation provisions 69Section 3700 of the'Labor
de, ,shall forthwith comply with'those provision
Co
,/Date:�0* 1"02 Applicant "- I 1 j
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, iri
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, indemnity
& 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 Or inspection Purposes
Signature (Owner/Agent) :Date'
CONTRO/^tK�L#
BUILDING PERMIT PERMITyi,9
422
DATE VALUATION &I.,J.��i�1..3t� LOT �� TRACT 218,313
JOB SITE
ADDRESS %9 Q� G��.7. . � [i
APN 149-210.003
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TD. DES
SPARKS CO3 KrRt.;M10'N1
P.O. W111 17 6
79.215 RANCHO LA Q#.iK1'dlDR.
LA QL11NTA CA 9.W3
1.A QU1N I'A CA 92251
l7613177t-1941 2996
USE OF PERMIT
SiNGLE f AN111,V 1.1WE'Li..ING
Si D, F^ i, N NO, LO 27, ia.EMfl'C DOES NOT INCLUDE BLOCK 'WALI. OR
NIJCiI., PLAN CICHCK FE:r,RFDUCED 75°,b I-Olth4t)Uri .N1.1 18sUADtCL; of
SANW PLAN TYPE.
CUSTOM COt' S"1 RIX ION 41243-00 SV
1"ople,i•1 -111 I0 511W SF
GlU AtiMARNOM' 7100)
e>STIMATED r:aST OF COINS T R V (71 OIN1&
t,:�Q�3.1i11
C )%iS'r1tl7C'CI.; N FEE 101-00"18-000 $1,521.50
'f1d.AN G"uF:rX i; FF 101.01 Mi -439-3148 ?T►R."f�
NTC°liANIC AL V M 101-8114421-000
fif. GI TRICAL tE 101 -000 -420 -OW S246,71
PE.iJfv11 YNO FMi 1014010-419-000 �r2f r5.t►t)
V114ONCs F04'- - ktOM!-) 101 -()}7t) -241 -MO S� at,14
CRA1DWO Fr -J: 101-000-123-000 $2fl.t>tt
lhjFRAS°`M,(ft"i'[ Rf2 ' rfM 225400-443-•342 S6,6W.00
ART .IN PUBLIC PLACES - Rh SH, 701-000-255-fJi)(? $628.47
I,T1.3,1"f li'A,1, CONFFIRITCTY-DW ANT) PLAN (7JECK
$9,1022.0s
(
117►'.t Af, £':ERM1I`l' 1+ EWS DUE NOW
&9.1191.11"
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RECEIPT r
DATE q
BYE/r- �`jt. _ ',
DAT FI ALE
INSPECTOR
r`�. /i1�1 )
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
l�- _
/
Underground Ducts
Ducts
Slab Grade
2 Cl
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Framing
G _ L�
-
F.A.U.
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
�! a
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
Water Piping
�,1
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
y�
6C
Pool Cover -
Encapsulation
Gas Piping
Gas Test
_
Appliance
Final
COMMENTS:
Final
Utility Notice (Gas) —At e zL
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
t
Final 2
Utility Notice (Perm) / _
I
SP.ECI'AL INSPECTION SERVICE
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
O REINFORCED CONCRETE O STRUCT. STEEL ASSEMBLY O
O POST TENSIONED CONCRETE O ASPHALT O OTHER
O REINFORCED MASONRY O FIRE PRO�O-FIING
JOB ND5 CA (+ e- � n L -54
/4 LA Q U : r `''
�T
REPORT SEQUENCE NO.
TYP OF_51RQJTURE LOT*K
PERMIT NO.
DA EI
G1
I
DAY OF WEEK
MATERIAL SCRIPTION
ARCHITECT
I R
HRS. CHARGED
` ( T- ( I
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
TEECTIpN CONT GENESUB
DATE ACTOR S PA e K CeK'C CONTACTOR p -
XTP TG p
o � ►v\ T
I12.� ^le
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 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.
8-�
CL�
4 1 SIGN URE OF REGISTERED PECTOR
SR
.5C.A O 972s
ATE O REPORT REGISTER NUMBER