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0308-047 (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 ry# Li c. Class Exp. Date 0/04 0 t Date 1211LI93 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 C,Ln I EEpUrILIC NSU Policy No. - Cd00u 8400 (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 Jvorkers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions: Date: .- ;/Wr Applicant— Warning: 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 t construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. Signature (Owner/Agent) �f�'J / Date1� BUILDING PERMIT PERMIT# DATE VALUATIONLOT TRACT $,1241,466.6o% 2932:3 / ;1 / � i • : �a JOB SITE APN ADDRESS��`•71t�.'.iiw.�A`�.f�s..�ri0ra�ii.4.i�.r' OWNER CONTRACTOR / DESIGNER / ENGINEER UTIMM HONM 0F` C.A1.3 Z0.RWLh l..MAIAY2 HOME, 9 OF CA,UX7ANIA 78-401 CHiCiHWAY Ill 78-101 CYHOIC'dtrJtiY l I LA tlL1MA CA 92253 .t A QT;aZNTA CA 92253 cm0p77d0131 MIR 3434 USE OF PERMIT _ Swome FfiN L XDWRT� 1N0- S..70 - LO`T, 4,'PLAN 213. PEZMIT DOES NOT INCLUPt BLOCK '!'liA.LLS., P001, SPA OR �i.UV AY APPROACH ' t TRACT CONSTRUCTION 203.00 O PORCHIP.c TIO d .tt0 Si+' j (3ARAGEWARPORT 44300 SF I I1 ..'I`]j;.' Ct'I' ' `C is ?> %J 0 ! 1:12 `66.60 �U7'.e.�97 n'.r-: e��JlYJI.•��tO.Yci MISI TRIiCTION FEE 101.000-413-000 $720A PL A14 CHPICK FFE 1011-000-439-319 $528.95 MECHANICAL FEE, 101.000.421.000 S40.50 L.UEC:TR1CAL lrKE 101-000-420--000 $115.35 PLUKUINO'KE 103.000.419.000 $14011 STI OHO MOT 10'24 PEE,- RESID 101-000-241.000 $12.25 011.AO1NO FEE 101-t 00.423-000 315.00 DEVEfX)PER IMPACTFEE �,•SOs.0i1 SUB -TOTAL L CCyI+7S`E TJC` ION PaM PLAW C" 1-TfE`X ' U335 TIRE—PMP dr' rOTAI', F—ERWISTIPM DIT.& NOW S4,0 �7M V RECEIPT " DATE�� / BY f D INA I PECTOR INSPECTION RECORD "'4. OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings _ Ducts Slab Grade'S _ ReturnAir ~ Steel _ We Combustion Air Roof Deck t.y Exhaust Fans O.K. to Wrap I _ _ 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 (� _ on_ 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 _ Electric Final Waste Lines xv 1.104 T= Heater Final Water Piping Plumbing Final Plumbing Top Out ©� Equipment Enclosure Shower Pans - O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection G - Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring _ i140 Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power _ Final _ Utility Notice (Perm) t 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.�01C� CI POST TENSIONED CONCRETE O ASPHALT O REINFORCED MASONRY O FIRE PROOFING O OTHER JOB LOCATIONg j !LA p" -y' REPORT SEQUENCE NO. TYPE OFTRUCTURE �j "�„ 1� -•f" O.f��Q. PERMI(T�]NOO. W� DATE 64 DAY OF WEEK MAJERIAL DESCRIPTION ` ZI ARCHITECT INSP CTOR HRS. CHARGED EN (NEER ^� �Cr.�a1 `lam • \A:�,�"iC± ASSISTANTS HRS. CHARGED INSPECTION DATE GENERAL CONTRACTOR Leg\(`qr A �CONTRACTOR �- • t tz' + �i VJ S i n n 4%'j Z;- A r>> 13 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 MV 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. E. SIG URE OF REGI ERED INSPECTOR Z. 13 (z DA OF REPORT REGISTER NUMBER