0210-268 (AR), LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes- Chapter 9 (commencing with Section 7000) of Division 3 of the; Business and
N W Professionals Code, and my License is in full force and effect.
C :5 ch License # Lic. Class Exp. Date
129362 D �j
AC 05rJur
LU Date Signature of Contractorl
•
0.
J U ( OWNER -BUILDER DECLARATION
HUJJ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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)./..�
() I am exempt under Section B&ptiC.aLfoor this reason
N Date Signature of Owne,
�.. Z WORKER'S COMPENSATIOWDECLARATION
0,2 CC I hereby affirm under penalty of perjury, one of the following declarations:
LO O () 1 have and will maintain a certificate'of consent to self -insure for workers'
X W I: compensation, as provided for by Section 3700 of the Labor Code,for the
O � Q performance of the work for which this permit is issued.
m Q U :1 I have and will maintain workers' compensation insurance, as required by
O U Q Section"3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:.
� Z Carver Ej�.4tT Policy No.
Ob 5
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g (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't ose pr visions. t ?
/Date: Applicant— f n r i ,• s"c.. a.-
�. PP ���
Warning: Failure to secure Workers' Compensation coverage is unlawful and s
shall subject an employer to criminal penalties and civil fines up fo $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code,,•interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1? Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) :'_,Date
/ :.'....
BUILDING PERMIT PERMIT#
fl-
DATE VALUATION LOT TRACT
JOB sl{E
ADDRESS 494.)55 C.ALLE1MO R/A
APN
1531-771-005
OWNER
CONTRACTOR / DESIGNER / ENGINEER
l SIC;L ,fit 71< S. ' �TtiLT `.1
BUTCH RAIM GONStIMUC1'7.. 0M
49-055 c:ALLEMURA
53.92,s AV:c?r€'IDA YTWARRO
LA QUft,'TA Ck 92235
LAQtif1>STA CA 9225:
(7160):564.2?V C!FILR TIM
USE OF PERMIT
EN T&r}2tOR }2TtMODE#;L. OP K.I'TCHEW WITH 219 SF AIMITION PER. APPRZOVED
t -
T1tLL�� �t9, ppgg �ctt9�YY d Ap AA..a}�� (� rJJ
TJ;rsl. R1k.P Od+% is 1}9,43 ,00 LS
ADDITION }.}i.tt0 SY
VOTMAM COST oil, CON91RUGIMA
1291020140
P1i;.11k.' T I'.ik SUMMARY
PW, 4 CHECK FEE 101,000.439-31'e
MECHAINICAIJ FM, 101-000-4-21-000
MYC., T•RIC:A.L )YRZ 1 01-000-420-t OLI
,'i�1�ll}1 I1I1!�<41 101-000-419-000 'a3t•1,0O
,tST.:?O: O MOTION M? o R�.33 1.01- 000-241-000
7k =3CiT .t.'�P$r ;1Trr"1'i.C31�i' C"`�1�€[E��`K
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CITY OF LA QIJH%TA - -
FINANCE DEPT. t 11 e-- i
RECEIPT DATE y
BY 1�
D FI�AL�E/p �)
INSP
fP
INSPECTION RECORD
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 CJS_
Compressor
Insulation_ G
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath3l
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
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:
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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 UCT. STEEL ASSEMBLY ❑ 0
❑ POST TENSIONED CONCRETE 7 ASPHALT ❑ OTHER
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION ' CAt + '+' A L A
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REPORT SEQUENCE N0.
TYPE SSQ E)RE / A- n �en _
(�� j
PE I O M ^
1� O3
DAY OF WEEK
MATERIAL DESCRIPTION w T
l/�4,•r {J
ARCHITECT Co O
INST;OR
HRS. CHARGED
JY`GIENERAL
ENGINEER � /
ASSISTANTS
HRS. CHARGED
INSPECTIONu sue(`^J•
.---DATE - - CONTRACTOR _ A. 4
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,^C.ONTRACTOR
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COPY SENT TO CLIENT ❑
CONTINU ON NEXT PAGE ❑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.
US IGN URE F REGISTERE SPECj)R
DATE OF REP I
RT REGISTER NUMRFR
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
O REINFORCED CONCRETERUCT. STEEL ASSEMBLY ❑ S�+
O POST TENSIONED CONCRETE ❑ ASPHALT THER
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LO - O �t O 464 C, O %lv l �'
�``7`/
REPORT SE,OUENCE NO.
TYP OF iy1�CTUR�_\i�o ^ J
�!
PERMIT NO.
OAIE/���
DAV OF WEEK
MATERIAL DESCRIPTION
ARCHITECT
INS 'TOR
HRS. CHARGED
GO gf.h A �
ENGINEER &
ASSISTANTS
HRS. CHARGED
INSPECTION GENERAL , �( -\� -COSUB f��
L--�
DATE CONTRACTOR {/�^NTRACTOR �� J S 1 `- '" "'
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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.
UYT; a,
TORE OF REGISTERE SPECTOR
Oa
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DATE OF REPORT REGISTER NUMBER
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 ❑ STRUCT. STEEL ASSEMBLY
O POST TENSIONED CONCRETE ❑ ASPHALT
O REINFORCED MASONRY ❑ FIRE PROOFING
/ r--
'❑ OTHER �
JOB IOCAT10N
�
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REPORT SEQUENCE N0.
ok
TYPE OF STRUCTURE
-
PERMIT NO.
DATE
2- 2-
DAY OF WEEK
o
M ERIAL DESCRIPTION
1
C
\jtW� 2 A
ARCHITECT
``FmAlm
INSPECTOR
Ys
HRS. CHARGED
ENGINEER ,
ASSISTANTS
HRS.CHARGED
INSPECTION
DATE
GENERAL
CONTRACTORI'o .�i
SUB
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COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE ❑
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.
C* -o �'oh' b, y\
IGNATURE OF EGISTERED INSPECTOR
l2 ICBG ?7717-$q
DAT OF REPORT REGISTER NUMBER