0308-250 (SFD)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
728102 .8 HIC cJl�f�i�
Date. Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm.under penalty of perjury that I am eiempt from the Contractor's
License Law for the following reason:
( ) 1, 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
r
WORKER'S COMPENSATION DECLARATION
1, 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.
Q 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 OLD ROU OUC: ENSU Policy No. MWC1004"540D
(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 those provisions,
Date:Rl–Ta Applicant—
Warning:
pplicant 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.
f
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 applicator 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) ,l(J //%, ,-/,X. Date/.� !h
BUILDING PERMIT PERMIT#
!
DATE VALUATION LOT TRACT
24
JOB SITE ;.
ADDRESS Y�73a
APN �^ 'vp �y,
[8V-�i�P/Z- ry009
OWNER
CONTRACTOR / DESIGNER / EN INFER
MWAR F101.4-08 01, CAUP-0 011 ;.
LERIN R HOTa S F CAIMO NiA
78-40'1 C,:�1+-UG��1W'.�Y I1
401^��CT:',�I+RCsGSrV�'Aa I I I .
�.}p F1ry.y �y
1A �►L1Ig'3TA� CA 92253
y7€�3� .yh/ -++yyryI9Q
LA t�GJBaTA CA A.?,253
x
(7-0)777-01.11 CBL9 344
USE OF PERMIT
nI:aaurs DWEU1JNG
SF.D. LOOT N, PLAN Wea-Am Pjt.d"c.MIT DOES NOTINCLUDE E BLOCK �.
WALUS', P0014 SPA OR :UWEIWAY OAC14
TRACT Cia12S`'AUCe`TION %902.00 O
;
POSiS.tilPATIO •53.00 SF
C3.AIti.AMCAC3.PCtRT 462.00 3F
+
7 '
. E 6c MWXK9D COST CIF CO1?7STRUC';. ON
17113 "1 , .120
MRA 31TE 9EIMMARY
CC')NMUC:9'IOM RE • .-1�JSsOCat3b4l as300 vi3t3l,SD
OM
PLAN, ME= FFE MOM
NEC HAANICAL rEE i 01-000-421-000 .678.00
Z11..WITPLiC 1r iF ER, 101-0001120-000 $Isvo1
PL1.tMf INO F3sE 101-000,419-000 w $11,35.25
5:"I'RCD11U MOT1frtAi FEE -RVORjI7 .101-000-241-000 $17.14
G RAM0 REI? 104.000-42391006 S0.00
D.EV;Et:.L'1MR.1}1RPACT 102Z
SUD- TOTAL MMTRsic IOW AW) !�LAX CRACK
A '
*701
ULU NO
CITY Or LA QVN A
FWANCE DEP7
RECEIPT
DATE
BY
D Eel N
I PECTOR
/_7 • / 5
e ,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
s BUILDING APPROVALS
MECHANICAL APPROV4LS
Set Backs A_
Underground Ducts
Forms & Footings — ��� _A
Ducts
Slab Grade _
Return Air
qz
Steel ) J� - _ _
J -_ `
Combustion Air
Roof Deck
.,Exhaust Fans
0. K. to Wrap _ _
F.A.U.
Framing
Insulation 3
Compressor
Vents
./� _ _ _ _
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
_
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
IM ^
Final
Final -'m
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 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 --Y
_
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole on
Underground Conduit
Rough Wiring
Low Voltage Wiring
_
Fixtures
_
Main Service
Sub Panels
_
Exterior Receptacles A.
G.F.I.
Smoke Detectors
Temp. Use of Power All
Final
_
Utility Notice (Perm) �� .� 4
SPE'CIAL-INSPECTION -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 2�
INSPECTION�..'v
PERFORMED
❑ REINFORCED CONCRETE
❑ POST TENSIONED CONCRETE
❑ REINFORCED MASONRY
❑ STRUCT. STEEL ASSEMBLY 400^(-A
❑ ASPHALT . ❑ OTHER
❑ FIRE PROOFING
JOB LOCATIONt
U; Pam a�
L-� 0011 1
REPORT SEOUENCE NO.
TVP OF S RUCTURE�� e �� �fi�, �y)v
`F
PERMIT N0.
-
OAT
DAY OF WEEK
MA L DESCRIPTION
M Sc•�
ARCHITECT
INSIECTOFt
HRS. CHARGED
ENGINEEER
'
ASSISTANTS
HRS. CHARGED
INSPECTION
DATE
GENERAL SUB
CONTRACTOR �— t e �� ' . CONTRACTOR -
�c M IN
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE
OF
CERTIFICATION OF COMPLIANCE
I 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.
T E OF REGISTERED PECTOR
SMI
(c3NSSq) 1zZ1?-
DATE OF REPORT REGISTER NUMBER