0211-053, 0210-141 (SFD)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 ! 11 Signature of Contractor��'J''
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 issued. My workers' compensation insurance carrier & policy no. are:
Carrier T.A ? P3P� Policy No. 04694MI
(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 sall forthwith comply with t,,, ose provisions
4�C Applicant—
Warning:
pplicant 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.
c.
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 inspection purposes. t
}�� h. ¢+ .'o Date
/Signature 0 er/Agent .1 �.
• : _'BUILDING PERMIT PERMIT#
DATE VALUATION .yam LOTTRACT f
243 1:
JOB SITE �^ q�—.- �{�.�y
ADDRESS r-49,tU V_. _A_MX ii\iJQ
APN
0&-2O 002
OWNER
CONTRACTOR / DESIGNER / ENGINEER
kalMRS LARRY WERIQR '
D1,124 7 = i�i'LI1Hi:'m. MCI.
P-0 BOX 11899
81?50 MfF4S0
eaUI CJ.?�A CA 92,0:78
nqW.0 t;,j;, 12201
(760)7754W C'814f 1546
USE OF PERMIT
WSCEIL,AMMUS
OTI,P011.40 P-111; AIT 014LY LTJ CU Y-13 TO1'r3I.) TO MATE? <A.r1PRO`V'PN%
GOMPA.C'TED PAD PP.tO.R TO 00N8TPUCVf N OF WN ID
V A,LaJA1 iCrH 14,op . o I'S
AdyryiT
AXW
M.Pii%)NO Wit 101-000-423-000 �2�s5G
a
WfE RU ICON .ra►�3:i�`I-:6`7��:��.A��yY C XW .
$22,30
NOVIT 11
2 UQ
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE E �i F
BY �,/.' / it
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts 24 Z
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
Final
BLOCKWALL 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
_
Waste Lines
Gas Test
Electric Final
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
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
Utility Notice (Perm)
9 1�
COMMENTS.
12
r
y= ! 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
;. N w•Professionals Code, and my License is in full force and effect.
C) __J M License #. Lic. Class Exp. Date
f CY r-
ll 5ri I 1o4
UJ 645369
ff .�
' roZ Date's' J°1" '�" Signature of Contractor.
co 0-
J U coo OWNER -BUILDER DECLARATION
W W I hereby affirm under.penalty of perjury that I am exempt from the Contractor's
~ d License Law for the following reason:
co ( ) 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
1 contractors to construct•the project (Sec. 7044, Business & Professionals
Code).
C'') () I am exempt under Section B&P.C. for this reason
LO
O N Date Signature of Owner r
d Z WORKER'S COMPENSATION DECLARATION
p .� I hereby affirm under penalty of perjury one of the following declarations:
LO .< Cc O 1 have and will maintain a certificate of consent to self -insure for workers'
X W U_ compensation, as provided for by Section 3700 of the Labor. Code, for the
mJ Q performance of the work for which this permit is'isstied.
Q U �9� 1 have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
IlLO
permit is issued., My workers' compensation insurance carrier & policy no. are:
NT z Carrier WWE, Policy No. 2,29-99 UNIT ftp` II047 ,
co0
J
(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-10 become subject to the
r ;f
worker5,compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions ofrSectlon 3700 of the Labor
Geode, 1 shall forthwith comply with those provisions-'
r 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, inde
& hold harmless the City of La Quinta, its officers, agents and emplo
2. Any permit issued as a result of this application becomes null and v
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancella n.
I certify that I have read this application and state that the above informati n is
• ° correct. I agree to comply with all City, and State laws relating to the buil ing
construction, and hereby authorize representatives of this City to:enter on
rthe above-mentioned property for inspeyction:purposes. f
Signature (Owner/Agent) 1.` Date.'��`'
r.
H BUILDING PERMIT PERMIT" . 1 11
0210-441 00,
DATE I _ VALUATION LOT TRACT
�i�,��.r� X4°8 LWt'. �
JOB SITE' }R- ,_.
ADDRESS%I-rA�.�i�rp=.ff i��0v,
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I'm & 1104 W Kul EEP
J, A. DOLW ClOwa1;iWr'u rfoli
PO BOX 1899.
'14-315 BUYTI01 OOD 1XVI%TT,
CORONA Cry 92£1TPS
PALM DEUR3° CA 0-2260
C7 60)340-46228 M-Xif , 5248
USE OFyyPERMIT
��E P Y DWYWANTIG
SFD .. LUT 1.4.1. 'PLMT i:I ES 1400 P+tCt..1JOK 111DI K b'IfALb„° OL,
SPA OR DWiZZWA ''APPR<3ACH
i•
bi. C I.CIN . , -1��t'.?od.�go fir .
VI�i�'!qq'p®�A7,,RHIv'zzMy�'h�,Ty
Ap�e(��.rf&/V�i><T
Y 17y,..n 00 SI
g ` +61-44l,
�PjaAJa�t�'�A.B,rJyfRA
PX'kMfJCFYE SUMMARY
C01.41ITRIXTION FUR 101.000.41��,.-000 A690.00
Pd. 4 CHIN112t F) -?El 101-000-x139449.8 $1,3+3A:?7
"!'EE DF;POISI T 101-000-439=318-s1pld'n
'
=xaICAI, 101-.000-421,-000
FL .I`€'TUC'•AL TMP 101.000.420-' 000 1213011.0
PI.bJ3, BING IYAB 9.01-000.410-000 $331.50
STH{:sW MOTION' KE . MID 101.000.241.000 r"p,66
DZV)4.•L-OPZA IMPACT f;
AR 1' rH PUBLIC 1=1.:,ACES-121!,.SM 270-000-445-000 1,41
+s•
r+
10A3PI-TarAL COi:1WR "3 RLAR t ITT -1"i
LFW P%-111AW 1"I
41.0.0 0.00
e _.
DEC 122002
CITY OF LA QUINTA /
FINANCE DEPT. ✓
RECEIPT..
DATE./J, J j�j
`BY
DA EI FINAL"ED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
- j
Ducts
Slab Grade-
ReturnAir �v
Steel
Combustion Air
Roof Deck
-.'3
Exhaust Fans
0. K. to Wrap
- -:5
F.A.U.
Framing
G —/a t j
Compressor
Insulation
=/�2_-�
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
l
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
_
Waste Lines
--/� -S
Electric Final
Heater Final
Water Piping_le
3
Plumbing Final
Plumbing Top Out
C/
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
-
Gas Test
--/�
Appliances
Final
COMMENTS: tJxrr�E,��se,•-�� f��cjs
FinalUtility Notice
{Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
S ��
jsl3 , y•4r7o�-,,� q
Rough Wiring
3
6 r/n® - __13
J
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
_
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final:
- -� -
Utility Notice (Perm)
. j
R
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 NTRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
O REINFORCED MASONRY ❑ FIRE PROOFING
❑�
OTHER
J08 LOCA
_ l -9 / V , ` e��,1
4`� LA-QuL
REPORT SEQUENCE N0.
TY OPTCSTUREU)X-4.0- o-e—4P--Z-5-PERMIT
NO.
D� 1,0 0�
DAY OF WEEK
MATERIAL DESCRIPTION A -�� / J L9D
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A8 MIT CT OAS �.
INcvc _
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G�-Lt, •
ENGWEE� L)
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ASSISTANTS
HRS. CHARGED
INSPECTIONI
DATE
L SUB
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CONT DON NEx7 PAGE O
T-
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MN.
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.
i
SIGN URE OF REGISTERED IN P CTOR
DATE Of RE RT REGISTER NUMRFR
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SPECIAL 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
❑ REINFORCED CONCRETE O STRUCT. STEEL ASSEMBLY • O
O POST TENSIONED CONCRETE O ASPHALT O OTHER
O REINFORCED MASONRY O FIRE PROOFING
JOB LOCATION
L�
REPORT SEQUENCE NO.
TYPE RE �y
Yi
PERMIT NO.
Q�
DAY OF WEEK
MATERIAL DESCRIPTION !
}ct
AR[I�ITE[T ` C^ ^
O+
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HRS.CHARGED
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ASSISTANTS
NRS. CHARGED
SUB
DATE CTION CONTRACTOR C � (� 1 CONTRACTOR
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COPY SENT TO CLIENT O
N
CON UED 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.
I -n� /
SIG JATPRE OF REGISTERED SPECTO
)tq,
DATE1OF AEPbRT REGISTER NUMRFR
,SRE.CIAIC INSPECTION SERVICE
REGISTERED INSPECTOR'S WEEKLY REPORT
JOIN TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
D REINFORCED CONCRETE
D POST TENSIONED CONCRETE
REINFORCED MASONRY
O STRUCT. STEEL ASSEMBLY
D ASPHALT
O FIRE PROOFING
O OTHER
JOB LOCATION �7`- SOD AVC ° DA 6k A� O ` / ,� d4(t' � _�•
K '�11,F/',7,L`L
/N11
REPORT SEQUENCE N0.
TYPE Of S7RUCTU/RE//� PEELIRMIT NO.
1 -105 1
DA
DAV OF WEEK
MATERIAL DESCRIPTIIONLLV/(` /�I/" ARCHITECT
5�v
INSPECTOR
HRS. CHARGED
ENGINEER vt�
ASSISTANTS
HRS. CHARGED
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//INSPECTION
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COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE 0
PAGE r OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV
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.
i
SIGNATURE OF REGIS D INSPECTOR
f'L- O2 AD 111(306-469) 1/
DATE OF REPORT REGISTER NUMBER
W V Em M &I
ON R
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 ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
REINFORCED MASONRY O FIRE PROOFING
❑
❑ OTHER
JOB LOCATION -7 r �O®
A61CA ®A re o. t ( k ou,t
REPORT SEQUENCE NO.
TYPE OF STRUCTURE&AF
D A QW- I I
NO.
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DATE
! 2- 3
DAY OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
INSPECTOR
HRS. CHARGED
LEAL DROP 909
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ENGINEER � _ ` ��
ASSISTANTS
HRS. CHARGED
GENERAL SUB &A/Z� �� WZ
DATE CONTRACTOR CONTRACTOR
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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.
SIGNATURE OF REGISTERE SPECTOR
;��
P 2 -23—o2 sc Mow -goy
DATE OF REPORT REGISTER NUMBER