0111-262 (BLCK)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,, _ _ � _ _ • � __ , �,
f
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 affirrr} 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.
Set I have and will maintain workers' compensation insurance, as required by
ction 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 1011j,_AI`11 MINA) Policy No. 164132.01
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) .l 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 oflfSection 3700 of the Labor
Code, I shallaforthwi h comply with those:provls ons. f
Date:✓/ s Jf J 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 Ouinta, 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 r<bove 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.
Signature (Owner/Agent), - ✓ ✓ ✓ ! Date//1),Ir
BUILDING PERMIT PERMIT#
DATE VALUATION 'LOT 1 � TRACT
JOB SITE
APN
ADDRESS 51 —.16.20 t' Q.MFa�'�.�J74,'TDA cV f. L .Z.
'773-043-W7
OWNER
CONTRACTOR/DESIGNER/ENGINEER
WI[".A FAME ' I'AR i'AXE FtWIP
A 2 Z MAN; ONR
JOSHUA .t, U, CA P225
r
%'Y iftl;� t3y �t3b Crk ��f 065
USE OF PERMIT
(KCIAMAIT, c. liit
30 i..F ACObRk3f'f+d.:(i TIOR 4v iUtTA.JXV' IL3 u0AUJ'6 CkFRL"k.X0 WA,f,..L PEI,, CITE`
STANDARD
b r1% SYI"I,LL m0 ov 4F
.i+lad ,L7i.'XJd G: 1a) W'6 N'r OF 1.r I I I 1.4 V'4.�'iIS.O:r).Y
RX)"CfDID
NOV 27 2001
C;7 IFOFJAC�UltN4
ow! cGb.� n,k, $(n:€CJ g /.1M)' ''':t, AN Ck3'FMKI
$31.00
I 0 �' ?►,i'I:DT?'f: �
$0.00
•�'
.R:'k.�' A.AL 7,' �7" d��a.' S'. IT A�'.A�M5 P 6 E NOW
i
i'Ai 1.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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
v
Exterior Lath
Drywall - Int. Lath
Final �-
Final
BLOCKWALL APPROVALS
POOLS - SPAS•
steel
Set Backs _
Footings i Z
Bond Beam /Z
//
Electric Bond
Main Drain
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
Final a
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)
COMMENTS:
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 y- "'p
❑ POST TENSIONED CONCRETE ❑ ASPHALT ❑ OTHER
❑ REINFORCED MASONNRRYY� ❑ FIRE PROOFING
JOB LOCATION 51-32,0 U ENi 0A- -3%AARE-2— L dt �1,t /4.!
REPORT SEOUENCE NO.
TYPE OF STRUCTURE AFT
5 FD �Q. Ct l.l.Ml� :
1 MIT N0. / / ' n
`
DATE r ® 7-
J
DAV OF WEEK
MATERIAL DESCRIPTION
S�" dv.•� Xe; -r- teaSZ-7
ARCHITECT _
?'AuE SCss'i PASS",
INSPECTOR
i�.
HRS. CHARGED
"OHEZ
[&SSISTANTSENGINEER
MRS. CHARGED
INSPECTION GENERAL'• SUB
DATE CONTRAj t
Pe t WaCL 'Cle5 CONTRACTOR (RNA /V�450A0l� Gvi✓al2e{�
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COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE O
PAGE t 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
?1 �4-1 �-�
SIGNATURE OF REGISTEWD INSPECTOR
` .��5-0z yrcfo1/I/326-V9
DATE OF REPORT REGISTER NUMRFR
I