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0403-040 (BLCK)LICENSED CONTRACTOR DECLARATION I hereby affirm underpenalty 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 129976 13 SDC 5131/04 pate j r Signature of Contractor' OWNER -BUILDER DECLARATION 1 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 fATF. Ir'JND . Policy No. 046-03-00090" (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 provisions. Date: e: �° ' s 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 laddition 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, 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. ig an lure (Owner/Agent) `7" ~ 'f �~ Date r2 - a BUILDING PERMIT PERMIT# DATE VALUATION LOT ()403"4)4) TRACT 3/ MM &4.9ftlrk JOB SITE AP�NN /' ADDRESS ,�1^ 4 TOi�.1~t�O LA S(,�%UTA ! 1(o- O Y/-Od? OWNER - ,Zj CONTRACTOR / DESIGNER/ ENGINEER :amu :1'WWAN 18710 VM YMtaM- PALOS VffZ0F a PIa NIwa USE OF PERMIT C3�.�TJE"1t�.� I�T3:Il�J�JCI DEV 75 -161 SEGO LANII� Sur.rR F-3 CA 90794 P:FtJC.Ii/a, DE.IMT CA 92211 (760)368-19333 CD-Lfi 6851 140 LF. 6'GARDEN RDEN WALL 4P $3 IAF. 4' I?ZT.1UN1NQ WA.LI, CITY STANDARD 6 FF. 'S ALI, 4 FT. WALL 93.00 LF RM.Kt"1"ED COST OF C:0XS1R-UV..n0N 1s'1"t'.RMIT ;hX& tiZ%MNARY ORRTRUC'•'TIO1 FEE 101-000-41.8-000 -000 $72,00 MAR 0 3 2004 CITY OF LA QUINfA- FINAWr•C nm®T L=S i' T'.T:.I -,PAMT=51 TOTAL %'I=:IWD 1035 DIX NOW RECEIPT DA r � � I BY E ` I DATE J1p/7AL L} / INSP �� 4.%8.00 $$72.00 $0.00 $';t2 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 Root 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 j Z Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final 9' 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 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: �/ aK- 6 / /Z`15116 \ V r SPECIAL INSPECTION DAILY REPORT TANDWS INSPECTION INC. PO BOX 13766 PALM DESERT, CA 92255-3766 OFFICE/FAX - 909.769.9717 PAGER - 760.776.3339 DESCRIPTION OF WORK INSPECTED OBSERVED SINGLE PASS AND COMPLETE JOINT PENETRATION WELDING ON COLUMNS AND BEAMS. SEE ATTACHED FABRICATION REPORT. SHOP WELDING COMPLETE 5/12 - ALL CJP WELDS PASSED ULTRASONIC TESTING BY INLAND INSPECTION. WELDING INFORMATION DATE TYPE OF INSPECTION PERFORMED SHOP WELDING CERTIFYING AGENCY AND CERTIFICATION NUMBER 12 -May -04 PHYSICAL ADDRESS PERMIT NUMBER 79-091 TOM FAZIO LANE - LA QUINTA ELOY CHAVEZ JOB NAME TYPE OF STRUCTURE HARMAN RES. @ THE QUARRY SFD ARCHITECT ENGINEER KRISTI HANSON YOUNG ENGINEERING GENERAL CONTRACTOR SUB CONTRACTOR RAM DEVELOPMENT WHITES STEEL DESCRIPTION OF WORK INSPECTED OBSERVED SINGLE PASS AND COMPLETE JOINT PENETRATION WELDING ON COLUMNS AND BEAMS. SEE ATTACHED FABRICATION REPORT. SHOP WELDING COMPLETE 5/12 - ALL CJP WELDS PASSED ULTRASONIC TESTING BY INLAND INSPECTION. 1)'T'I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK, Io - � UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS WORK INSPECTORS SIGNh4RE TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS & APPLICABLE BUILDING LAWS. ICC 1111326 - cc: INSPECTORS CERTIFICATION AGENCY AND NUMBER r WELDING INFORMATION PROCESS :r &A 0-.;- NR232 WELDERS NAME CERTIFYING AGENCY AND CERTIFICATION NUMBER ELISEO VASQUEZ EARTH SYSTEMS #ES1038 GUADALUPE AMAVICA EARTH SYSTEMS #ES1183-34 ELOY CHAVEZ EARTH SYSTEMS #ES1275 1)'T'I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK, Io - � UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS WORK INSPECTORS SIGNh4RE TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS & APPLICABLE BUILDING LAWS. ICC 1111326 - cc: INSPECTORS CERTIFICATION AGENCY AND NUMBER r IM STRUCTURAL STEEL SHOP WELDING FABRICATION REPORT Job Name: AMRIMW '?6i4. ®iW O v A -R ►2 j' Contractor: 'Rom DEI' Physical Address:-9Q9,_9J rV»'7 r4e-10 Lti, &-A- GzuiN77Q Engineer: VOuNlr Architect f-KAIOSoa.i Fabricated at: "21LO ir:S Sit- StartDate: 5% fra.Oq Finish Date: 540—.6411, QTY PIECE NUMBER ASTM # Amo SHAPE t-, . SIZE 5x5x'/y SINGLE PASS WELDING Rce, WELDING DATES REMARKS C®luw7rV�3 � �� A5oa Q &5x W ACC l I RSO S �S Y.i Ace I 10 j15oa 6�L8>L(/2 P,V`-�- �.a (u�m Pj'3 l IP- Fr 3(o S x3 f P1 Z RM 5;12 eturoco forth'- fi_RO*.Ac- I e, lg3b -T: 1P K 31 AnCC P(W- 5,1Z uw �© Y C5, I 1� )3fo T_ 1(0x31 ACC Act, SIZ 13 o �r�i �►� • All materials conform to approved plans, specifications, AISC, and AWS D1.1 unless noted. • ACC in SINGLE PASS or OP WELDING columns represents acceptable welding and no corrective work required. • NDT stands for Non -Destructive Testing such as Ultrasonic or Magnetic Particle