0211-012 (SFD)LICENSED CONTRACTOR DECLARATION
f Uj t I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
5 ch License # Lic. Class Exp. Date
CY
UJ 911$ 0110
Z r-- Date '� Signature of Contractor -tel F
(D 0.
J U C) OWNER -BUILDER DECLARATION
HUJ r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C0 () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
OC\I
CL Q WORKER'S COMPENSATION DECLARATION
p cc I hereby affirm under penalty of perjury one of the following declarations:
U-) O () 1 have and will maintain a certificate of consent to self -insure for workers'
X WLL compensation, as provided for by Section 3700 of the Labor Code, for the
Om . Qperformance of the work for which this permit is issued.
< U (j) I have and will maintain workers' compensation insurance, as required by
d
Section 3700 of the Labor Code, for the performance of the work for which this
I:L::.•L < . permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Cartier. .AN11TON :; Ci, .Al Policy No.
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 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, shall forthwith comply with t s pro islons.
este: ^0.9 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 ihis
application.
1. Each person upon whose behalf this application is made & each person at
^� ti 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, indemnif
' & hold harmless the City of La Quinta, its officers, agents and employee D
2. Any permit issued as a result of this application becomes null and void
work is not, commenced within 180 days from date of issuance of s
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information i
• correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authofi ze representatives of this City to enter upo
the above-mentioned property for'ii'n'sp ction purposes.
],,'Signature (Owner/Agent)'✓ P14 �--�' Date
BUILDING PERMIT PERMIT#
01 2
DATE !� "` -7�j� VALUATION LOT ����ry TRACT
1 is -4
JOB SITE �e
ADDRESSjYrSt
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CAPITA 1, r -M, C H0I.i�r�3CS,'11Z
CAF.i`%Ai.MGAMIC atMS 19C"
CORONA. C.4?s. 92881
clk 91660
(,949)6ZZ-8400 C D11111F 15031
USE OF PERMIT
tw�'JLso F.ip JM.L.13
SYD - LOT 116y, PLAN I.A. PI?%t.MIT 00-kVi NOT 114CLtPD ,f3E OC;K'133s` Ui i,
VIDO14 SPA, OR DM + AY 4PPCtOAC-H
CVPTOM ("'ON 7M1J1;T1034 3,M.00 V
IaC7Fc'.MPt TIO 1332.0 SF
C#A11.ACa1;ta MIORT 700 SF
C'ONS'i'RUr,:T ON 1'',11; 101.000,41.8-C►W $I;ai+ so
PLAN CHECK I FFT 101-0004."_318 $1,1'k"ag
M.zCHANI"ALfqK 301-000.421-000 $ 12,99
,VuA.S�
.�IvvCA/10-00y
PLUMI--31401 FER 01.000-419.000 $ 323<';,q
STjiOW0 MOPIUl IV4E = 3iI 11D 101 -WO -241-000 $31,99
GR&P. W 1''.RE ',, 101-000-423.000 $0,00 .
IJEV94..0I*PIL IMPACT FEZ, $a,o.t1U5m
P$1: :I fig FLAN 101-0610-4 41.34 8 V00.06
ART INPUBLIC PLACFS - RFMr. 2701-000-445-000 gW.1a
r
81373,1-'1'441. i:'C?N +�1`;£ DC:°1;[03 -AND PT.M C%P?ZR.'.
$6,11 6
LESS 11IR&PAIDMI. sS
<:
7
JAN" 0 g 2003
CI
FINANCE DEP
RECEIPT JDATE BY , DATE FINAID — INSPECT
I
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
p — S
Ducts
Slab Grade
Return Air
Steel
30—
Combustion Air
Roof Deck_
3
`3
Exhaust Fans
O.K. to Wrap
. 03
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
z
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final 5
BLOCKWALL APPROVALS
Final —? 1— L5
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
—_Z2— cS
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_ 6— D 3
Encapsulation
Gas Piping
Gas Test
— D3
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 — 2 -.3
Utility Notice (Perm) — — j
COMMENTS: 0 45
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Aver
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
W
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE TRUCT. STEEL ASSEMBLY
O POST TENSIONED CONCRETE O ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
Cl
HER
JOB LOCATION
g' gbo C C- 01 VS G U `�
(�
REPORT SEOUENCE NO.
TVPE�STRUC
RE 0 O
6` 1GJ
PERMIT NO. ' x' '
V
DA 0�
DAY OF WEEK
MATERIAL DESCRIPTION /
ARCHITECT
IN!aPTOA
HRS. CHARGED
LdINSPECTION
ENGINEER
ASSISTANTS
HRS. CHARGED
DATE
GENERAL__.,`� ,. G.�SUB
CONTRACTOR_ 111 CONTRACTOR
lw. iES
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COPY SENT TO CLIENT O
CONTINUE NE%T PAGE O
PAGE F
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.
>�J(
I AT RE OF R GISTERED IN ECTOR
DA 0 REPORT REGISTER NUMBER