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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
1311 '484 '6 8r
Date Signature of ContractorZ.f -
yt'� �z l r �_,•-
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 ;;T.A1'1T FUND Policy No. ill�fla�-�1D�3{?i: >2f X33
(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 Latin ,
Code, I shall forthwith comply with those provisions. •• -- " "� :�;p �-' ,✓";,�
•D'ate: Applicant 1 �••' ✓ `- 'i t �" 1'I ,`` t
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties an%d•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 fc� inspection purposeslx� `
Signature (Owner/Agent)%^ ^ f i ' t t`/x� Date
BUILDING PERMIT PERMIT
DATE 34,rj VALUATION 112',0.00 LOT TRACT
-
JOB SITE
`ADDRESS W-915 AVE WA DUZ 'ADDRESS
_
OWNER
CONTRACTOR / DESIGNER / EN (NEER
:CA 9P,2. 3
LA QY}'LVrA CA. 92IT531
�76T5 23.0315 C'M0.
USE OF PERMIT
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INSPECTION. FVI.?P4 EIVf F140,03f.l E NOT Ii40.1A,ff ED
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P1v.RMIr 1i'.1SX 811MRIARIN'.
PLAN CHECK ILLI°: :10 1 -000-439-318 U7,75
C 0141S' RUCTION i 'S 101 -000 -4.18 -WO
KITM&NICI&L FEE -- Po(?l. 301-000-4`d i -owt S�4,Ocs
'PL VC:TRICAL ItEF - P001, I M _000-4210-000 y4S.e36
'.w F'I,LiN3I3FN0 RE- POOL 101-000-419-M10 7`P• 0
aJ���✓^.1 �•;�.tC]L (l~'s�lLi!n'91t��o LOL>.�. h�JAV .l'l.atlA%- 3'�.\�.�Y, �.'nZ:.dLY.o2:.
C;�J � S'.7. Y a
M.WQ PRE -PAT) M202,
$U00
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CITY OF. L1')UP',JT.\ n
HNANCE criaTe
RECEIPT
DATEa �
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..By ^"'�
=•-•
DATE FINALED
IBJ G�
INSPECTOR
.^f!, .4.:
__
INSPECTION RECORD
i
OPERATION
DATE
( ( INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade .
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K 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
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
I -':t BacksElectric
Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment location .
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAL'S .
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 s
AQpliances ,
. Final —
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 i
Utility Notice (Perm)
COMMENTS:
N•1
-,-
FIELD MEMO
Project Name IV d (�A-Q �Gt (� Client:
Site Address 5 (Gc`Zr
L
Job Phone
Work Done
Test Summary / Footings Inspected
Test
No.
Location
Elev.
Dry
Densis t
,= Moist
%
% Relative
Compaction
Ref. Max
pcf
Moist
%
Sladden Engineering
t (2-
-
6782 Stanton Ave., Suite A, Buena Park, CA 90621
(714)!523-W52
Fax (714) 523-1369
,.
39-725 Garand Ln., Suite G, Palm Desert, CA 92211
(760) 772-3843
Fax (760) 772-3895
/4
Date
K:
:f
Job No.
-2 -Z
-,-
FIELD MEMO
Project Name IV d (�A-Q �Gt (� Client:
Site Address 5 (Gc`Zr
L
Job Phone
Work Done
Test Summary / Footings Inspected
Test
No.
Location
Elev.
Dry
Densis t
,= Moist
%
% Relative
Compaction
Ref. Max
pcf
Moist
%
t (2-
/4
Comments
Field Tech. _ Super. or Agent
24 hour notice requested to schedule Field Technician. Thank you for the opportunity to be of service.