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0307-047 (RER)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 Date 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 �0.�mpensation, will do the work, and the structure is not intended or offered for 'sale.(Sec. 7044, Business & Professionals Code). ( ) 'I, as uwnel of the property, am RCIUSIV81y contractirig with ,licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). ,*�? O I am exempt under Section B&P.C. for. this reasons e /.�. /Date Signature of Owner %�,,.�i• 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. (This section need not be completed if the permit valuation is for $100.00 or less). ,U71 certify that in the performance of the work for which this permit is issued, I sKall,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. fl - Date: Applicant 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 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, orreessation of work for 180 days will subject permit to cancellation. �• t. I certify thatJ have read this application and state that the -above information is correct. I agree f&,,;cornply 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 inspectio purposes./ j ,-Signature (Owner/Agent)y Date BUILDING PERMIT PERMIT# DATE VALUATION • LOT' TRACT. 1� 237773-1 '7' 18 JOB SITE 7 APN ADDRESS 78-745 CJ.00N WAY W9.470 -WD OWNER CONTRACTOR / DESIGNER / EN INEER DCTTSLE TM1 R € ► iERd Bi'7II .EM 78.7.43 0PJ014 V-3At% L%Ae',IMtiI,A r CA 92233 MIA USE OF PERMIT 711187) C)M QATdAM CO"NVEFcSLON T0,80NUS ROOM P'ERAPP11,C76rHD 1?t;��J,nbgl c�L�C. CONTRACT AMOUNT �pnw LS 3,747.60 F`lF RW,V T'i`L+ E t UMNUR9t CONSTRUCTION FEE .. 101.006-418-000 03104 PLA14 CHECK FZZ 101-000-419-315 $55.36 NIEL4-1.ANICALFE4✓ 4t7'i-9l1© 21»Cfl(9 $19,50 ELECTRICAL",E $2.05 STRONG MOTION F.EE ,R941n 101.,: 00,241-000 5.90 PA 1�4 2003` �-./IIJUL - CITY OF LA QUINTA FINANCE DEPT. _ x.RM-TOTAL C0NBTR_LVC 10 IFIL k?L/+,R3 6Or a $1X0.11 LSM PXJE PATI) F i�fi,.dXD r(YrAL PEIM 1s;, yak: ea r MOM RECEIPT DATE BYZ-... �/ D �J !PEQW— V� 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 L _ Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath II - Int. Lath AK Final Final POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. 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 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 Low Voltage Wiring Fbdures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) JCM Inspections 39725 Garand Lane Suite F Palm Desert, CA 92211 INSPECTIONS Phone: 760-345-5554 -'Fax: 760-772-3895 INSPECTIONS EPDXY INSPECTION REPORT Date: $-O3 Project Name: Project No: Project Address: City: (� QC�ori \,a u�:���, \C,� Title 24 AIMS File# E]D1.1 App# ❑ D 1.4 ❑ Other UBC Other: Client: Sub -Contractor: 0 General Contractor: Architect: Structural Engineer: C ® Anchor Bolts Rebar Epoxy Type: Epoxy Shelf Life: �� 1Q, ,� p ess Hole Cleaning Method(s): ��c��a n C �c���.rC - Q C ��\� E.d c. �r Weather: Unresolved Items: None ❑ See Below Description of Work Inspected: pyG �v\ 4��C go �a r a1J� Je c i ori �wne \Nocx r,�Nl cQ_ Ct S;X e. / �L, r#. i n c+ \t r 1 ` 3 A� � - � � �. bA 1 � \..�� (�`.. Q_ Dpi l C?1_. ' n 1 7 �' X � eT � �°+ ^ � 1 M� C C•O \ C_.S { O at -v 0. G A,- r n c n^ r n A GL Q c^ +J v,_ •S Work complies with written approval from Structural Engineer and ICBO Evaluation Report # I hereby certify that I have inspected all of the above work, unless otherwise noted, and to the bestrof my ability I have found this,work to comply with the approved plans, specifications _applicable building laws. Final report issued at project completion. Inspector':-Jck C. Millin ICBG eTt rld t'o No: 0842216-49 �' \\ Contractor's Representative: Copy 1 JCM Inspections Copy 2 Project Superintendent Copy 3 Governing Agency Page I of