0212-074 (RER)H
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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
604455 BMC
d ate z '* t3 -2 -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).
( ) 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 certificate of consent to self -insure for workers'
compensation; as provided for by Section 3700 of the Labor Code, for the
erforf,9ance of the work for which this permit is issued.
have and will maintain workers' compensation insurance, as required by
ctlon®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 STATE FUNI:.i Policy No. 1640114
(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 37 0 of. he Labor
�-„ io
Code, I shall forthpith comply witf�t e'provlslo
&Applicant
SA�
Warning. Failure to secure Workers' Compensation cove age 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 representatives of this City to enter upon
the above-mentioned property for insl p`ection purposes/1.
S gnature (Owner/Agent) t +'��Dateo
j2
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 02.12-074 TRACT
JOB SITE��t
APN
ADDRESS 55--107 COd'sC3fREi4eSeIO1 A1,
»
OWNER
CONTRACTOR / DESIGNER / EN (NEER
RICM1DRADI.OFF
B.C. (MNSMUG"tT N
55-937 C0140Rs<.S&RIONAL
RO. 1:3OX3206 ....
LA. QUi13 rA CA 92253
RUM =10=, CA. 92260
(766)776-6085 a..C3u 5$71
USE OF PERMIT
MIS=J_4,k&_C)US
R2PAI1: 01? fes€ ACICKI) SLAB, MC3TING & f1lMV,IN93 C+' 14C RIV..I M, PER MAN.
VALUATION 3,090,00 La
`. .TEJ) �COS''.�,' OF ClIG19'L117707C..'�'i�; 0
�1ti€�YiTi)
1����//]f`�yYS 7+y;Y�� �l�t��/y /y,4 ,►g, -p r'
d` U.I.'6.f.�A7.T dJ ,7ft,X.I & V nu6.iVl27tY,�a. Z
PLAN 10J•.1ECK FETE 101-000-439-316 SM110
CONSTRUCTION FEE 101-000.419-4)W $54.00
STRO N O Mt:>THYN ME -1.OID 101.000-211.OW $.-30
®�a =M� At, C., RTMOMM AR+11.+ PLAN (LIM S
$89,60
D LMS PRE -PAW MEJ
$0.00
DEC 2 0 2002T( L, F M fly,S 1)UN Now
CITY OF LA QUINTA
FINANCE DEPT.
Voxo
14RECEIPT
DATJBY
%?s�'
C„meq_
DATE IN ED
IN P CTOR
3
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.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
BLOCKWALL APPROVALS
Final
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
r
Underground Electric
Underground Plbg. Test
Final I
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
N
Bin #
City of b Quinta
Building U Safety Division
P.O. Box 1504, 78-495 Calle Tampico
la Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit # D
�\� •
Project Address:JAddress:
wner's Name:
A. P. Number:
•�
Legal Description:
Address: ' �L� ({
in•. ST. Zip:Contractor: elephone:
oject Description:
CitN'. ST. Zip:
e-
'Q, �
A
Telephone:
ne:ILt
A is Y1
6
State Lic. # : !C
Cin• Lic.
Arch.. Engr.. Designer:
Address: - C) O
City. ST. Zip: D
Telephone:
O rll tyP e cu ane%c
State Lic. ±
e(ci
ect
(circle one): New Add'n Alter Repair Demoi1
Name of Contact Person:
Sq. Ft.:
# Stories:
#Units:
Telephone # of Contact Person:
Estimated Value of Project: 3 000
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Recd
TR.•ILCK1NG
PERMIT FEES
Plan Sets
Plan Check submitted
Item
Amount
Structural Calcs.
Reviewed. ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
10
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2nd Review. ready for correcti issue
Electrical
Subcontactor List
Called Contact Person w4,7 Z
Plumbing
Grant eed
Plans picked up T %�
IYI aZ
S.M.I.
•
H.O.A. p roval
Plans resubmitted
Grading
IN HOUSE:-
'" Review. ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
No**.25IL LIZ
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City of La Quinta Building and Safety Department
Plan Check Corrections
Str..u.cturat
55-837 Congressional Architect: Alcumbrac Architects.
La Quinta, California Plan Check No.: 0212-074 (1St check)
Date: 12/17/02
1. From the information provided we cannot ascertain what the applicant is trying to achieve
with this repair. If the building is undergoing differential settlement then the repair given is
only cosmetic in nature and further settlement may render it ineffective in the future. Our
suggestion would be to have the applicant engage•a geotechnical engineer to determine if
there are settlement or other geotechnical concerns that need to be addressed. If so, a
qualified structural engineer should provide a report addressing.any damage or proposed
retrofit/remediation work.
Plan Reviewer. John W. Thompson, P.E.
Phone No.: 760-360-5770, ext. 102 Fax No.: 760-360-5719
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