0112-053 (SFD)u. LICENSED CONTRACTOR DECLARATION
t 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
1.44 094 A BIRO 3n� 1/03
.JDate '+%' t �•( '` Signature of Coniracf,5.1 -+` tti � --' s� •n
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).
O I am exempt' under Section , B&P.C. for this reason
Date • Sign2tuFe. 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:
Carrier2a� RICH 4`s.� EMCA� Policy No. WC' -02,20M3
(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 shall forthwith comply -with those prove .
ions
Date: f "' F f%a e �+s APPlicanT �, T .. y.��, ,
, .:
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 Fon 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+i
work is not commenced within.180 days from date of issuance of sL
permit, or cessation of work for 180 days will subject permit to canoellatI
I certify that I have read this application and state that the above informatio . is
correct. I agree to comply -with all City, and State laws relating to the buildi g ..
construction, and hereby authorize representatives of this -City to enter up n.;,`
the above -me ntio4d,-prope rty for inspection purposes. {
e a'��
'Signature (Owner/Agent _.Y � °—""f tea•"` Dater V .
_ y t V
BUILDING PERMIT PERMIT#
DATE VALUATION LOT
44"��
TCT
28960
JOB SITE _ _ /.
ADDRESS
9 D 9.MXud�%Atldi t�f �ijl�S" _
APN
I-� QA�
769_M
OWNER
CONTRACTOR/DESIGNER/ENGINEER
' ;tm H0.1V6.8 - IAtLIMI) BUM,`• MV=
,N ("&M= HQNk M
71289tM�,'r�PW CIRC" E SLIM 1.50
2280 • IARDLOW GMCLY„ SUF E 150
CORO �A )1 X40
t~��fi�l�
CSA 017210
-
'(909)279-4000
PBLO. 5761
USE PERMIT
yO�Fgry y��� gyp y y� �7� y ��q�q
62tL.4'i`1011 :'.�C11d38��1.SyS 11 �.S�hni.aid•RS7
1
li>~`J : AST ;1 PLM QAPL PERMIT DOES NOT 04C;l.UDE BLOCK WAi, L
POOLMA OR DRIV9WAY APPROACH,
CUSTOM Call- IMIU'C TION 3.142.00 OF
+'.) C6 1?Bi'CiC9 434A 9F
C1P tAWCARP00 x.60 SP
T...MMMV 00ST ,4)ta. C"OE TRUC,17ON
264,204.8D
1"RIWrrlff M >SUAGUY
C°O STRUCTIOW = 101 -OUCi„43 U-000 ;31,21-i D
PLAN C'kl:=VF Z 101-000-439-318 S.M. 15
rOMMMICAL FY9 1011000.421-0(X) MOO
RAISCr:YUCAL,MPM 101-000.4.2"00 $175.23
PLUMB= FU 101 -OMI -419.000 %x199,75
31,C1d.OisOM0"±'RON My. REBID 101-000-241-000 $26.43
t e33A.13 NO RT, 101-000-42.3-000 %20.00
M1 BT'R>;.ttC URE FRE 225-000443-342 51.,07.00
ARC IN WUB14C; MAW, R.09 1T 270 -000 -445 -NO MOM
rp
<,2
08—q L ;fiapC�O AWL) Pg p q CH=
IMS YRE-FATD n, ms, .Q10
I
sl
UYfAL PXXOM liTES JXTE NOS
o, W21
WYOF LAOUlNd?A
RECEIPT
DATE
i M
B. -�
F ED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
O}. _/�
Ducts
Return Air
1
Steel
Roof Deck
O.K. to Wrap
_
_ DA/ !
a�J
Combustion Air
Exhaust Fans
F.A.U.
_
Framing
_ _
`j� �
Compressor
�
Insulation
- _
S�8 82
Vents
Fireplace P.L.
Grills
_
%
Fireplace T.O.
Fans & Controls
Party Wall Insulation
i
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath S.11_(o D2 3
i
A1
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
/
i9N(��
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
_
Sub Panels
_ _ -�
le,_
Exterior Receptacles
_
—
G.F.I.
/
Smoke Detectors
Temp. Use of Power
Final
/ /��
Utility Notice (Perm)
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 TRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE b. ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑ o di
THER W
JO ION
-
REPORT SEOUENCE NO.
f_Y
Tg�LC7URE� �J
`
DESCRIPTION
PERMIT NO.
D!5t5 6 AY OF WEEK
MATERIAL
ARCHITECT
NSP CT O _ HRS. CHARGED
w I
^
ENGIN O ot- ���0
ASSISTANTS HRS. CHARGED
INSPECTION
DATE
GENERAL u- ��S CONTRACTOR
NTsue
CONTRACTOR v-` �p_•� ��G�
OR
—SA0
O uJ 2.L.,6 t V4(41q-s 1T r1 o 1,
L !0 S Lo 16
Go CS
S�c,Ja� ��► Cou►�rP �
I Z
WIZAA>
_L.A�• Gt.T
LSC- 9
COPY SENT TO CLIENT 0
CONTINUED ON NEXT PAGE O
PAGE 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
If NOTED, I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS
SIA URE OF REGISTERED 2PECTOR
ATEGFF REPORT REGISTER NUMRRRFFRR I