0308-050 (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. Date1/ Aq
72S102 B HIC 09(30/04
Date IE43 Signature of Contractor!-��
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 OLD 1-M1= 2t3.LXc, rNeal Policy No. MWC1008454946
(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 c=on
compensation provisions of Section 3700 of the Labor
Code, I s., all forthwith comply with+,those, rpvisjo !
Date: _ '�j� Applicant /G,
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 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
e� 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
i:' construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property,for inspection purposes.
Signature (Owner/Agent)' r'�/fft� Date
BUILDING PERMIT PERMIT#
DATE VALUATION�4�-p LOT-"{'� TRACT
I y
80129,M, 9323
JOB SITE
APN
ADDRESS 1<3-,0011WRKWAY.�`.rMMPNN. DE,, X."
OWNER
CONTRACTOR/DESIGNER/EN (NEER
LS�.k4'k -P& HC)j ms OF C:AI.t� e'3mm
LENNAIR 1.101404 OF C',A1'..NTRNTA
78401 C HECvTMAY 111,
78-401 C 11TCr AY' 311
I-. Quit. 'Tp, CA 92253 .
LA QVINTA CAS, 02213
(760)777�0131 C13TA 343/
-
I ISF ()F PFPAAIT
`i1 ou" )E:on"Y 1)WVmL,T1,3t;
SYD - 1,0T I, PI.AkW 48. PERMIT t"aiJ1;eS NOT INCL lD9BLOt;`IC IVA,P.I,
1>001 g SPA OR DRIVEWAY Y A,11PROACH
W
TRACT CfJNSTRUCTION 21225.0 VF
PO CNPPA 110 53.00 3P
Cf.ARMIMCARPO tT 423.00 SF
E9TJWXi?�.1, COISTWr d;ONSIMUMON
129XVAD
A1A04la ly
CONSTRUCTION, ITZE 101-000-418-0040 $744.50
PLAN CHECK FEE 101-000-439•.318 010.`7
MGCHAt+i1C AL F'EX 101.000421-000 $47,00
VIVI ;TR.t,G.AL FEE 101-000420-000 1r119.8t3
11�U1tii1',11df1 t"L' 101.0001-4!9.000 $146.75
SiF`kC►rFri,S MOTIOM PEE - faESID 101-000-464.3-000 $1.1.99
Ciu"DING i ZFI 101.000-423.000 $15.1110
D9V 1.OPZR. LWfPAC T FEE $%+:05. DD
AND P�catI..�`�Iy��T�pp'' IX
T4,1011i.85^
p,!./
?� � C4
� XS3 P.[4d3.- A"nU) I-MYS
TOTAL i1'? IR'wr t+.LEES DUE 'Novi
V
RECEIPT
DATE
BY D T FI L ^^
INS ECT R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVA S
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
_ _
Ducts
Return Air
_
'
Steel
ki V_
Combustion Air
Exhaust Fans
F.A.U.
_
Roof Deck
O.K. to Wrap01
Framing
-
Compressor
—
Insulation
Q
Vents
_—
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Finalt
4�,l —/
_
POOLS - SPAS
BLOCKWALL
4;;,
APPROVAL
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP OVALSGas
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
40,.iQ
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPRO AL
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) /
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
78-194 Elenbrook Ct.
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--304—
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
E-pc"K'
❑ OTHER `
JOB 4ATION
3- �3�
6��J . La, v;
REPORT SEQUENCE NO.
TYP OF CT RE
V
TC�,C'e. y
L
PERMIT _„ r ��
14
DATE
Z '
DAY F WEEK
MAjERIAL DESCRIPTION
ARCHITECT
INS P CTOR
HRS. CHARGED
^�
INEER
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL
CONTRACTOR e
a
CONTRACTOR
`--
Lo
ei r
ke`
^J"
DAY
COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MJ
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.
p
Z 1SIG URE OF REGI � TERED INSPECTOR
3 �
DA OF REPORT REGISTER NUMBER