0308-051 (SFD)LICENSED CONTRACTOR DECLARATION
-•'•hereby affirm under penalty of perjury that I am licensed under provisions of
1hapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License,#99cC��ts4«)) ZLiic. Class Exp. Dattet Ybp
04
Date ��' "y� '/7 Signature of Contractor %�✓A !'
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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). I
() 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.
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 OW R.EP'UDLIC II ISI Policy No. MWC;f.pQ,ASA00
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, I shall forthwith comply with•those provisions
Date. 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 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.
Signature (Owner/Agent) r/• / /J` �!/.!/ r Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT )ilT`art:9� TRACT x
145 29323 ur
JOB SITE "�
ADDRESS 43 691 P,14,14KW.i Y ESPLANIADEr EA.K
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MMM 1I0MLES OF CA1, FORKIA
,F..t WAR HOMES OF CAI.:.OA CIA
78-4pP31 0IsUC41 1�'.�AY 111
784017T1�C•c'�IiA'tGHV�AY I I I�v�
Lr, QUINTA. Cly -02233
LA QU axe CA. 92.2.
('760)777-dI'31 CELS 343.4
USE OF PERMIT -
SM012, PAIMLY DVS I.;(NG
SM 1,.0't tax. NI—kN 32.B. w PEI't.t►1IT DOES NOT INCLUDE, BLOCIC
iffAI L01 F 001h :0A, OR D%WIrW Y APPROAC I•I
1'M c' T C LYMSTI UCTIOD 2,3-4,00 IF
PORC;.I:Y PATIO 43.40 ?
0Ai2d3MYC.7►PYORT 634,00 OF
ESTMA:1ED MIS Or C:4:l.IVIM2'MMOP
M N 011M C T I OWFEEE.I:�I «{9CSI •3 <�Uti X3.34
PLATT Cs?IX,K PT?S $659.56
MECHANICAL, ICAL, FFR 372150
ELECTRICAL AL FEE 1014100-420-000 $130.34
PUJIWBINO FEE 101.000.419.000 $1166,04
STRi91"CJ M0710r4 FFE . RESID 101 -NO -.241-000 '$14.30
GRADINO FEE 10" $'1,5100
OL'•t ELOP&R,1331+.ACT PEE $ 105.Oi9
SUB-MML CO..tME LTC;!'IOR AND PLAW C"TMCY,
$4:,236,20
;I'OT'A, PIUMIT F. EYE DUR: NOW
t4,2 20
V
RECEIPT
DATE
BY
D ✓�
SPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
01
Steel
Roof Deck
Combustion Air
Exhaust Fans
F.A.U.
_
,
_%
O.K.Wrap _ - _
Framing
Insulation
Compressor
Vents
—
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
f
Final
_
Final
POOLS -SPAS'
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROV .LS
_
Waste Lines "a
Water Piping --,GJ �ICCC///
Gas Test
Electric Final
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection /✓6 •d
—
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) — - - -
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring of 11) _
Low Voltage Wiring �'—T1
Fixtures
_
Main Service AL I
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final -
Utility Notice (Perm) ,
o e . ® .
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
78-194 Elenbrook Ct.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
O REINFORCED CONCRETE O STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE O ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
g-pCo A
O O -HER
JOB LOCATION
REPORT SEQUENCE NO.
TYPJE OF TRUCTURE
5-F bvLA
'T'.\.nes ® PERMIT NO. i
1ff�q O
DATE
Z
DAY OF WEEK
MATERIAL DESCRIPTION
cARCHITECT
INSP TOR
HRS. CHARGED
Zi
E=1 R
sb kA, hUc"1 • ��C;�' o C
A5515"TANT$
HRS. CHARGED
INSPECTION
DATE
GENERAL
CONTRACTOR e�- CONTRACTOR . C�
2�
7yAu1
2,SA W-%\\ Lo►v r
S
n!4 &,c,
o.c>>
!.3
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE 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, 1 HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE y.
GOVERNING BUILDING LAWS.
f -
SIG URE OF REGI EKED INSPECTOR
�Z 13 � dG30 �c�ZZZI'l`b�
DA OF REPORT REGISTER NUMBER