0006-132 (BLCK)LICENSED CONTRACTOR:bECLARATION
I hereby affirm under penalty of perjury,that I am licensed under provisions bf
Chapter 8 (commencing with Section 7000) of Division 3 of the Business and
Professional§ Code, and my License is in full force and effect.
Lic&ise # Lic40UEZAR�ATION, Class Exp., Date
b7 07 B 07/3 tee
Date 7.a%6� Signature of Contra
OWNER-BUILDER
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):-
1,
ode):-I, as -owner -of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, . Business. & Professionals
Code).
O I am exempt under Section B&P.C. for this reason.
Date Signature of Owner,
WORKER'S COMPENSATION DECLARATION
I hereby,affirm under pehalty.' of perjury one 'of the following declarations:
O 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 Js 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 STATS FUND 0014 N9. 4�6 OU
(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 mer- as to beccpe_-subject to the
workers' compensation laws of California, and ag ee that if I shobld become
subject to the workers' compensation provisions o ;Section 3700/of the Labor/'
Code, 1 shal[fort��Cvith comply with those provis's
Date: �� •a/.®' Applicants
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 day's will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to complyiv�ith all City; and State laws relating to the building
construction, and/hereby authorriize-repre a tatives of this City to enter upon
the above-mentioned propert�ifor inspection�p rposes
Signature (Owner/Agent) Date ��'
UILDING PERMIT PERMIT#
(jam //��
DATE T D - A ATION `4 LOT •-''. TRACT
JOB SITE °
APN
ADDRESS
50-30) WOORAIMk ..
OWNER
1J( ou
CONTRACTOR / DESIGNER / EN (NEER
LA QUl�3ids, € ''1'�d
S COavSIRU'C"'1101
PO BOX 1716
79.295 lZANCHO •U A Q'C►INTA DX
LA QiyIItPtA' CA, 92253
LA QL'1zAi'TC.A CA 92253
(160)771.1941 C.B14 . 2996
USE OF PERMIT
T3TJ1Z1"sL1�C
fa'mm_?ALIlk
600 LFA. 6H,120I2IJE'AI 1?TALL-ORCO STANDARD y
6 F�'i . WALL 600.001,E
EFI'.tri4�7,+'�'I�.D COST O11' %t7A�C�"i�.�•�.'HON . �
� 15,m30 w
yy���-,Ypy•��yr) •�'•�7•�g� SUMMARY
r.Fil.�.iV.i•Ji.J, FE7.S+FDLJtl).tVLt1R:L-
CONSTRi3CTION•!EE 1t91-000-4?"' 00
9UB.-TOTAL CONSrRUC'TION AND P�f-�{i(.�.1'N C BE:CX
$4 �2./Q�¢fs�
( ��
a..�f+.f 3 FRE -PAW 5.�8.w.. J
$0100
TOTAG FnMT'@XE_'5 DUE NOW
$162,00
RECEIPT
DATE
DATE FINALED
INSPECTOR
INSPECTION RECORD
'< OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Se'_- 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
Set Backs
Electric Bond
Footings
Bond Beam it b
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Final ��'
PLUMBING P ROYALS
Underground PIN. Test
Gas Piping
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
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)
COMMENTS:
,SPECIAL INSPECTION SERVICE�
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
❑ POST TENSIONED CONCRETE
❑ REINFORCED MASONRY.
❑ STRUCT. STEEL ASSEMBLY
❑ ASPHALT
❑ FIRE PROOFING
dX
❑ O R
JOB LOCATIONC.J� o 6--66-REPORT
SEQUENCE N0.
TYPE OF $TRUCTU E .. JPERMIT
S .
N0.
00 6-3 IR
DATE DAV OF WEEK
AL DESCRIPTION
ARCHITECT-.
Q
j
I HRS. CHARGED
6 �.
[MATE
riteE.9
ENGINEE14
- EEv
ASSISTANTS HRS. CHARGED
INSPECTION
DATE
GENERAL
CONTRACTOR
SUB
CONTRACTOR
Y
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D
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2 -
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COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE ❑
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.
i
SIG ATURE OF REG STERED INSPECTOR
DA E dV REPORT REGISTER NUMBER