0308-046 (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. Date
112810.71 St ITIC 9/30!04
Date?''Signature of Con tractorf�'"
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 01'D 1119PI i'i+1.1t;1WO Policy No. MWC 1'3031'13100
(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,tf' se rovisions'.
Date: �"�`'✓�� 'f ADolicant �' irk/ �• r'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
. the above-mentioned propertty,for inspection purposes.
rrSignature (Owner/Agent) h,; 169x Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT. 030 TRACT
/ ��j .
JOB SITE
ADDRESS 43-742 PARKWAY 11:1EWLAHADE EM. T
APN
60fL38"1 3
OWNER
CONTRACTOR/DESIGNER/EN (NEER
i..M.Wa HMMS OF CAL 1F(:Y N1A
1"'N". HOMES O.F. CIAL LiltMA
78.401 C FiiGMVAY 111
78-401 C IRGH VAY 1.11
U. Q2T.f rA CA 92253
Li, , CaUipvT CA, 92.253
`76q)?'?7-0,A 31 0.131.,. 3434
USE OF PERMIT
SVn - CST 5, PLAN 3YA..FEMMUT LitlM! NOT YNCIA)OF BLOCK WALT:;.?, `
:P001:IPS OR Z RJV WAY APPROACH
TRACT COW rT31.1 CTION 2,3".00 SP
P0iZCk�-iPAT10 , 45.00 SF '
C1AYAMYCARPORT 418,00 �P
PERM i''ri EX ST'Jm14J$mZY
CONSTRUCTION ION 3`EE 101.000.418.000 $°t"ils oa
PLA14 CHECK rSLe, 101-000-439-318
MECHANICAL FEE. 101.000-421.000 $47.00
EIZZTTWCAL fq,; L? 101-000-420-000 $135.41
KuA10D;0FEE 101•00041:'-000
STR.0140 MOT1014 FEE, . AP -SID 101-000-2..41-000 X13.81
ORAWRO KF 101.000.423-000 51106
DLrVEL0PVR. IMPACT FEE, ��,dO5.t70
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T4,186./1 3
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v
RECEIPT
DATE% /
BY �'/lp }/
F L .�\
I SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR .
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
�_
Underground Ducts
Forms & Footings
Slab Grade
_
_
Ducts
Return Air O
Steel
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
.. v
F.A.U.
Framing
vQ
v
Compressor7-1
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
i
--
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
_'
Heater Final
Water Piping
_ _
i
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
64V -9W
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
f --
SPECIAL INSPECTI`OIV,`SE°:RVICE:
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
78-194 Elenbrook Ct.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (7613) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY���
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑ OTHER
JOB IOCTON � .
� � � v O
REPOT SEQUENCE N0.
TYP.E OFTR
V
""rn,p�S' `y
Y l`
PERMIT NO.
('�UCTURE
VJA,
o
DANE
'G. . e
DAY OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
INS P TOR
HRS. CHARGED
2�EN
EN (NEER
\�'. Q%
ASSIS@rANTS
HRS. CHARGED
INSPECTION GENERAL
DATE CONTRACTOR Q� CONTRACTOR
COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF Mr
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.
b
SIG URE OF REGI FRED INSPECTOR
Z 13 d 6ZO 5-cD L -11(q --i
DA OF REPORT REGISTER NUMBER