0308-252 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch,-�pter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect. r
License # Lic. Class Exp. Date
Date .,'` Signature of Contractor,�������r�'P
OWNER -BUILDER DECLARATION
UJ W ' I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ N License Law for the following reason:
Z_ ( ) 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).
� O I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O �
a Q WORK'ER'S COMPENSATION DECLARATION
> CcCc I hereby affirm under penalty,of perjury one of the following declarations:
0 () 1 have and will maintainma certificate of consent to self -insure for workers'
{ W LLcompensation, as provided for by Section 3700tof the Labor Code, for the
n J QJ performance of the work for which this permit is issued.
Q C0 (�)`. I have and will maintain workers' compensation insurance, as required by
O' Q Section• 3700 ofthe Labor Code, for the performance of the work for which this
LLO H permit is issued: My wo►kers' compensation insurance carrier &policy no. are:
oo 5 Carrier Policy No.
OLD REPUBLIC INSt?
i1aWIM54400
J(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 tho'se prove Ions.
bte: 12114. Applicant � ✓ �� �'
s Z 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• land 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.
Signature (Owner/Agent) /�-� ��'��� Dater -ate <7 4.3
PERMIT#
BUILDING PERMIT
DATE VALUATION LOT' ' TRACT
JOBSITE'
APN ►' y^
ADDRESS '78-448 WA FAVIOnr
OWNER
CONTRACTOR / DESIGNER / EN INEER
t1t l%i1A iii tR�Lii.51 CJS' L''RT e tCii21�1i�1.
l,;fsNTS 3 O'& ".� OF CAU_ `J.P.W1A
'78-401 C" 1 -MI- NVAY .1 l 1
78-401 C :Filch WAY 111
U Q T WA CA. 92253
1AQIJ'1XI-A CA 9 253
(750)777.0131- CBLR 3434
USE OF PERMIT f i
WT. -2X PLAN 4YC. PERMITDOES NOT 1NC1,UDZ 8LCaCK
WALLS,, LLI .,001.E SPA OR t7RffEWAY ,APPROACIff, W i`) .P,MOC7TION TO PLAN
dHZC1C lX1?, DUE TO Nfli71, 1PLia NSISUANC E OF SAMt PLAN 'd Y'PLI,
TRACT CONSTRUCTION 3:1140,,00 SIS'
PG)3COYPAT1O M.00 51p
GAR.AC;EMARPORT 42S',00 8F
r
F9111"rklCONT OF CONSFTCC10H
177,034190
t
q�rCggZE /qup1vii
CONS's'RUCI°! ION FEE 101.000.418-000 $912,50
PLAN CHECK .VEX 101-000-4351-318 $187.29
MEC3:ANICAL FFR 101-000-421.000 166.50
BY.1st.'TRYCAL s'191+; 101-000-420-060 $149.40
PLUM.B11401:TI ? Ot -000.41 M00 $172.00
5T1;iJNO NDTION PEly - t~.&S10 101-000-241-000 $17.70
CRADINO "KE 101-000-423.000 $15.00
��,�c►�.ofi.
j.%V1;'rr PL?R I.MPA :T. PEPLT,010
-3'%]I3-';►0T1'�t. CCA'Fs,.rYC'.l'IC)�i.�t�+`.��I.r`sN Gni',:
513,�'24.3�
YRE-Y'AID TIM
$0.00
(, A ;� I., FIh''�N1.If VIM D .E+ 1'40W
6-3,924-V
�.
DEC 15 2003
CIT`I Ol" LA QUIN TA
RECEI
Y
INA ED
NSP TOR
.7
hl�,cl
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs _
Forms & Footings
Underground Ducts
Ducts
_
_ _
"
,
Slab Grade
tum Air
_ _
Steel
Combustion Air
Roof Deck m —
Exhaust Fans
O.K. to Wrap -p
F.A.U.
Framing s
_ _-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
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 I I
Gas Piping
PLUMBING APP OVALS
Gas Test
Electric Final
Waste Lines
tteater Final
Water Piping i
Plumbing Final
Plumbing Top Out e
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) t
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
_
Low Voltage Wiring
Fixtures
Main Service/,�
Sub Panels �t�'
_
Exterior Receptacles _
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) /
M
.SPEC 1AL-1 N'SPECTION SERVICE'
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
78-194 Elenbrook Ct.
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
pe�
p%'j
❑ OTHER.
JOB LOCATION
718
u L& INNREPORT
—4,fM4 V \ _ A \ �V� �, �OIA
SEQUENCE NO.
TYPE OF STRUCTUREy �� Q� �j.�, �, �
L®41-vk
PERMIT NO. � -Q%2
�
� � �
DAV WEEK
MALT{.R`AL DESCRIPTION 2? � �
ARCHITECT
INS ECT R
MRS. CHARGED
ENGe ERASSISTANTS
Ccl � A F_
HRS. CHARGED
INSPECTION
DATE
f
GENERAL SUB
CONTRACTOR L ����(— _ CONTRACTOR
�eJ
LA -S Af
�,"<A ov,IN
O.S CSS
�1 B e wed At z
'S Ig ®tsJ
COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
47 1 HEREBY CERTIFY THAT I 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.
SIGjAT/qRE OF REGISTERED NSPECTOR
S 11-1-117-
t DATE F REPORT REGISTER NUMBER