0403-365 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjurythat I am licensed under p"rovisions 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
7 ar. fall• 74 z�. 13 /0,;
Dater "`% 'w� Signature of Contractor ' ' - �% t1s---
/ — / .�
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
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;ilS ue�1. rF�tiw rkers' compensation insurance cjftj 8�pslicy no. are:
Caner Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,.
1 shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of$ection 3700 of the Labor
Code, I shp'll forthwith comply with those prov'siopsp
Date: rfs Appllcant:lr!»�—_
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest, and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicator agrees to, & shall, indemni(ry
& hold harmless the City of La Ouinta, its officers, agents and employees I
2. Any permit issued as a result of this application becomes null and void i
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio
ir
I certify that I have read this application and state that the above informationi
correct. I agree to comply with all City, and State laws relating to. the buildin
construction, and hereby authorize, representatives of this City to enter up
the above -menti p roperty for inspection purposes. f
Signature `14Zr/Agent.) Date
BUILDING PERMIT PERMIT# 5
DATE VALUATION i�.tkt�ff� •- � LOT ^a TRACT .4
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JOB SITE x"13 • �.r..f .i
APN �'+r�'ve�r�•• (1 v�
ADDRESS
OWNER
CONTRACTOR /DESIGNER! EN (NEER
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{�7it5'.t' tlA�C fJWA �.1:f��/d'7..��?YI�I:E�:��'I''=.'��17P-
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f1 i'13$ rel : CA 92 17
IkODL ANIM CA 923 �
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Pk[.MCVb1S SUMMARY
CON1D`I"RUCTION FEE 01-1000-118-000 000 5105610
PLAN C.HZC . FEE Ii)I_000_4;$t-318 OKI, 17
M.ICHA.hd.ICAI.VEE lil:•C1i14-�y'I^QOIi 41b .DFS
Lam. M.,.A,. F.'F. 01 5."Y q
PL,I,IM.C1YNOf'.I? 101-000, 419.001 :110.50
STRI Y.40 M0T!( --a TALI? , RY—SID 101 -000- 41-600 $21.111
ORA17OW WE 314,00
.f_1EVELOPbU IM<ROXI" I' FRE, $2;405.00
ART 04 PUBLIC Pi,::Sl[ 2"711-Q00-445-000 $4.3•11
r
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RECEIPT
DATE .,
BYDATE
FINqED
INSP 9R
7/A s-
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
i o
Return Air
Steel
Combustion Air
Roof Deck
Q
Exhaust Fans
O.K, to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
SLOCKWA,LL APPROVALS
POOLS _ SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
r a e
Pool Cover
ewer
Encapsulation
Gas Test
App ances
46 -
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior ReceptaGes
G.F.I.
Temp. Use of Powe
Final
Utility Notice (Perm)
COMMENTS:
TANDY'S
INSPECTION INC.
PO BOX 13766
PALM DESERT, CA 92255
QI*f:f^IAI IM4MPVr `TInPJ P1AI1 V ==lMn9 r OFFICE/FAX 909.769.9717
TYPE OF INSPECTION.
-r
PERMIT NLAWBER
PHYSICALADPW-381d , �}S l� Gi4- N lA C"
JOS NAMff P , OF MUCTURE
ARCKTECT L.c.
ENGINEER
A
GENERALt A A�. SUBCONTRACTOR
1 HERBY CERTffY THAT 1 HAVE INSPECTED ALL OF THE ABOVEf OMrED WORK,
UNLESS OTHERWISE NOTED: AND TO THE SESTiPF MY ABILITY I HAVE POUND THIS
WORK TO COMPLY WITH THE APPROVED PLANS: SPECWATIONS 3 APPLICABLE
DAMING LAWS.
CC:
b
Ic'so Is®n
UMPECTORS CERTIFICATION AGENCY . NUMBER
DESCRIPTION -OF WORKr
SUPPLIER
TICKET NUMBER MD( NUMBER SATIIPLED IIME AM TEMP TEMP SLUMP TIME IN MIXER
+�$ U
J Q' �,�
V e 1♦�
VVELDING INFORMATION
PROCESS
WELDERS NAME
i � , _ Lei.:! A� ' 'Jl
. � • • ��`r�r � �
dk
Wq 7M
�a •_S\L�"�f'��a
■
4Z
1 HERBY CERTffY THAT 1 HAVE INSPECTED ALL OF THE ABOVEf OMrED WORK,
UNLESS OTHERWISE NOTED: AND TO THE SESTiPF MY ABILITY I HAVE POUND THIS
WORK TO COMPLY WITH THE APPROVED PLANS: SPECWATIONS 3 APPLICABLE
DAMING LAWS.
CC:
b
Ic'so Is®n
UMPECTORS CERTIFICATION AGENCY . NUMBER
SAMPLE INFORMATION.
SUPPLIER
TICKET NUMBER MD( NUMBER SATIIPLED IIME AM TEMP TEMP SLUMP TIME IN MIXER
LOCATION
VVELDING INFORMATION
PROCESS
WELDERS NAME
CERTIFYING AGENCY AND CERTIFICATION NUMBER
1 HERBY CERTffY THAT 1 HAVE INSPECTED ALL OF THE ABOVEf OMrED WORK,
UNLESS OTHERWISE NOTED: AND TO THE SESTiPF MY ABILITY I HAVE POUND THIS
WORK TO COMPLY WITH THE APPROVED PLANS: SPECWATIONS 3 APPLICABLE
DAMING LAWS.
CC:
b
Ic'so Is®n
UMPECTORS CERTIFICATION AGENCY . NUMBER
M
4
Pi ANn
L Certrficafee ofOccupancy
Building & Safety Department
77
This Certificate is issued pursuant to the requirements of Section 109 of the California Building
Code, certifying that, at the time of issuance, this structure was in compliance with the
provisions of the Building Code and the various ordinances of the City regulating building
construction and/or use.
BUILDING ADDRESS: 81-957 COUPLES COURT
Use classification- SINGLE FAMILY DWELLING Building Permit No.: 0403-365
Occupancy Group: R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: BIRDIE HOMES, LLC Address: 6 E. CITRUS
City, ST, ZIP: REDLANDS, CA 92373
By: GARY HARTMAN
Date: JULY 7, 1005
Building Official
POST IN A CONSPICUOUS PLACE