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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
456 :238 BMC /_;"'•� OMA8t2(
Date &S•g ature 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: r
( ) 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:
CarrierSTATE FUND' Policy No.
(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 that1f I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code; Ush fl orthw'th co_ ply with those provisions
Date:,- A, plicant
Warning: Failure to secure WorkersCompensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth 'on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspectio 6urposes. _
S' ignature (Owner/Agent Da e___Z J
BUILDING PERMIT PERMIT#
DATE VALUATION LOT Q�(rrs--moi TRACT
12 23935
JOB SITE
APN
ADDRESS MI5 f39;+i) .QESEEX
W4-332.41
OWNER %
CONTRACTOR / DESIGNER / ENGINEER
• DA1AOX C&N ON
EDWARD W-KORGE WJSE
43-093DF. MI' Alit
53635 EMMWOWER DR.
I -A. QUINTA Cf!: 92253
LA QUTWfA CA 92253
c?60)v1-1180 CBLA 2351
USE OF PERMIT
RT:M3 24 MAL ADDMOAT
296 S.1? R oov ADDITION. 2081 CBC
ADDITION 256.00 :1F
1s;S2'A1ad rMn CCAS' oF Cam,. zaTic-not
13pooso
PEIUffr FEE 5Y�1WAPt Y
PLAN CH CK FEE 103.000.419-318 S99AS
CONSTRUCTJO14 FU 101;-1".X80.41$-000 $153.00
1ARCHANIC'A'L, FHE 101-000-421.1100 $33.00
f ECTRICA,L F&F, 140.1-O0-420-OaO $32.25
STRONG MOTION FZI R • R&SID 10.1-000-241-000 11.39
s3ft�,i3I1J141rEi� 101-000421-000
r r.
SU.B-TOTAL CtONTrRUCOrOST AND PLAN CHFICIA1
$334.09
:t.,Fa93 PPY,-PATI) FEFS
$0,00
FEES 013F, NOW
JULMRNAT
18 2003
CITY..OF LA f UI!ITA
FIN�'� , UtRET. .
•
RECEIPT
DATE
�• '
BY "'�
T FINA
y
INSPECTOR
fii :� ��'
f
t�
INSPECTION RECORD
OPERATION
DATE
INSPECTOlf
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
.. MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Slab Grade
tj A I
Ducts
Return Air
Steel
Combustion Air
Roof Deck
/
Exhaust Fans
OX to Wrap
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
i O
Final
Final
POOL - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
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)
JCM Inspections
39725 Garand Lane Suite F
Palm Desert, CA 92211
W 92
1T..JJ
INSPECTIONS "' Phone: 760-345-5554 .- Fax: 760-772-3895
INSPECTIONS
EPDXY INSPECTION REPORT
Date-1.�5_
Project Name: Project No:
CCS G �rll-- c 1 \\'o
Project Address: �. City:
LIS— Nvc— 4ky
Title 24 AWS
Other:
09 O LrQ, k q
File # [—] D 1.1
App# ❑ D 1.4
Client: Sub -Contractor:
(;q-e%c
E] Other
General Contractor: Architect: \ Structural Engineer:
oY TC���ot� K •M . <'
a a [s.r�c�c1
F-1Anchor Bolts r,Rebar
Weath, o \-)
Epoxy Type: �1 ir``t.�So/N J Vf oAG
Unresolved Items:
^----
Epoxy Shelf Life: ccQn , d�S
® None
Hole Cleaning Method(s): \,pvwn 0eq V1 f�( \12Q
❑ See Below
Description of Work Inspected: & c� CtZ�`
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Work complies w ith written approval from Structural Engineer and ICBO Evaluation Report #
I hereby certify that I have inspected all of the above work, unless otherwise noted, and to the best of my ability I have found this work to comply with the approved
plans, specifications applicable building laws. Final report issued at project completion.
Inspecto Jack C. Millin ICB rt ication No: 0842216-49
Contractor's Representative:
Copy 1 JCTA'I?Spections Copy 2 Project Superintendent Copy 3 Governing Agency Page 4— of A—