0208-276 (RER)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
P_F±!-,essionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
���30� �rb►6C � * I?./3i Air*"�
Date f ' eSignature 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.
°(,Z) 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 SIFAITE CoUp 1�tilqjJ Policy No. iM5949.02'
(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,
Irshall 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
e Labor
Code, I shall forthwith comply with those provisions.
Date:: .� t• r 7 Applicant
Warning: Failure to secure Workers' Compensation cover ge/s 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 andSafety
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. r
Signature (Owner/Agent) r +' `�' r r Date #� Fi'
tY y
1
BUILDING PERMIT PERMIT#
DATE VALUATION M ; LOT TRACT
JOB SITE
ADDRESS �-Itai �r+r�EekT
APN
OWNER
CONTRACTOR / DESIGNER / EN INEER
KEMW ViR.M."Lom
3 co,
$5475 LAURM VALLEY
13730 JAGUAR WA.1'
;A Sa1t1Y CA 97=3
PALMDESERT CA 92261
(?60)341.333e CI:1LP 3259
USE OF PERMIT
Fxmy1alfhAqql yd 4 0D L
AO ?iNC6 fit?Nfif;12 TOPOW DEIt ROOM MLOC;ATEINO TOILET ANL"
1,00-ATjNCI WATER R*ATRR TO dAiA10Z
VALUA170-0 IX
t,
EMMAMM COST Ole C0"NsilatTrion
$=.00
PERwr Alm SUMMARY
PLN CHECK FEB WX
OON16 i"MUCTION RM s 01-000418-000 4991.00
M.1ANIMs FEE 101-000-421-000 $dl."�
6, tXC'mIC.AL IEEE 101-0.0 06420-000 830.45
FLUKOM0 FFX 1 CJI.000-443.9a0O0 $48,00
STRUNQ MOTION i&t" o XESID 101-000.241-000 $.EO
+A�
83Cl b-�Yi1CA 1120144"J(1r2'UC;TIONAM XYLAN C1 MCK
$264.10
YDS PRP—PAID EM'S
$0.00
DJAS
tv Ir 72':]13
CITY OF LAQUINTA i
FINANCE DEPT: - R
RECEIPT
DATE
BY
I 0 NALE
INSP R
'r -
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
L4
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing G V
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
_
O
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 A PROVALS
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
COMMENTS:
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)
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
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
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
kTHER
I
JOB '
�j 9 L / A L)W,- -( 0 1 0e LA l/1V , Tf�
ll_. 11 /`—(X/�
REPORT SEQUENCE N0.
Tv TjiL1CTUR`E"rLv foe—e—\<�
P RMIS, 0
0 O�
DAY OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
INSPECTOR
I—
HRS. CHARGED
if
i 0 A
(, `�`F�-
CYJ
ENGINEER
n'O t
(\/n�JC
ASSISTANTS
MRS. CHARGED
INSPECTION
_DATE
GENERAL SUB
CONTRACTOR _ -CONTRACTOR-- -- -
p,U g" 14 17th
S{ -(w e.�c au✓J)P—k_ 9x o k --\.-
COPY SENT TO CLIENT O
CoNfkUkD ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
a HEREBY CERTIFY THAT HAVE INSPECTED TO THE BEST OF MY
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.
o�
W ` �
SIATUR OF REGISTERED SPECTOR
LACI ( II
m� �za lot
DATI TO
F R PORT REGISTER NUMBER