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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
P=rofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7176991. 13 d , 4,13=4
Signature of Contractor a
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 c&tificate 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.
II 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 Policy No.
L-11JORTY MUTUAL 13 WA.26eI3017.23012't I:
(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: / ' f `� 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.
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#
DATE VALUATION LOT Q402_163 TRACT
9M .687,60 2RR:38.3
JOB SITE
APN
ADDRESS
81-315 GOL 1Ji3 Y I PAW
762-4111
OWNER
CONTRACTOR/DESIGNER/EN 1NEER
TOLL RRCf i l:i.IM WC
f0.0. BROMERS LNC
73.121 14M WARINCv 0.100
'73-121 FM WARMY 4100
P.{a,LM D W uTr CA 92260
PPLVL VL DFSs r CA 92260
(760)674-9699 Cn 1,1f 3032
USE OF PERMIT
Lyyyy. yy_AA MY MY MM-1-1110
I
SFO r LOT 311, VENTAT A-A147c asiK PERIRI'P DOES NOT INCLUDI
BLOCK WAtS,L% POOL, SPA Oft DRIVEWAY APPROACH. 'M n
`N E DUI OF SA ErI..3td � n
O P1 ACHECK YR TO.MULTIPLE ISSU"CF,
VUSTOM CONSTRUCTION 4,: 4.00.SF FLMAR.
0 2 2004
PORi"WI' A IO 650.00 SF
C3AIACi)4. CARPORT 'x(1.00 Sri CITY Csf:
!A 4�1i:�lTA
i=1NAUCE
DEPT.
E 1'imt?t`.�L. D Cs'osr or CClmuci %..' n
PERM A FRE'' WIMMAr 4`
COAIST UCTION M 101•000.4118-00D $i,563.so
PLA114 Coir i':I WE 101-000-439-318 $1115.61
IJIZCHANICAL FFr,. 101-000-421.000 $1156.50
}:.=TRICIt L Y S 101-400-420-000 $203.69
PLUMBING FRE 101-t 00-419.000 $213.00
10 MOTION .1472.1iMSID 201-000-241.000 $36.31
OR DINO FEE 101-000.423.000 $15.00
I",?FiVEL.OPZP. IMR CT )YEE $1,40"x.00
ART IN :PUBLIC ,PLACE'S • REVE 270-000-445-000 5409.:22
SUD-"IADTAL C:OMMij'Clit7NAND PUN OJllrM�S;
322. t39
t. Z-0 PSM -PAID FERS
V6 010 J
TOTA, PEPMT F.I.o DUE NOW
RECEIPT
DATE
(.4/
BY
DATE I LED
INSPECT
�-/.
�.���
/ Z3 e
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footingsa
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck B
Exhaust Fans
O.K. to Wrap Q
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 o
BLOCKWALL P ROVALS
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
Suli, Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
JCM` InspectiOS
39725 Garand Lane':Suite•F
Palm Des4ftZX,92211
INSPECTIONS Phone: 760-346-665:4:..•c .Fa*•. 760-772-3895 INSPECTION S
... ..: a r� . 1 ..
EPDXY INSPECTION REPORT Date: (0
ProjecTame: Project No:
P o-je}ct-°Addres-s�:�1 } Ci Title 24 A:WS UB Other:
c� 4� �1 �l . + �•i�?� �A� cm%c L File # O D-1.1
F•
Client: Sub-Contractor: .. App# ' DIA
GCGC:. Q Other
General Contractor • Architect: R� Structural Engineers -.
.§?�7 (fir :_ •. 1�. � C� � u v `pr
•Anchor Bolts E].Rebar Weather:
E6: T e: trt�SOn. C:) (N Eni
\_ Unresol ' ms:
Epoxy shelf Life:
`(1None
Hole Cleaning Method(s): A ca v i rl :
(A u n � f� f' e, — 'C LJ 'A'. c?�< t F, .e c e, a�C <, Q'See Below.
Description of ,Work Inspected:16c \\o e�\a,� ,5 d a
ae4 Q"n.t
S �1
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� $ � C .G' � � vaC SG. �. �:; X �. •e�..:.t "h. ca, : �:�C�I5. Vii. :On c, �: �,..
1.
•,� M '-INS. e,:`�.Y \p v.7•:
SA �,� ! �qii` :, b'Or�! tA,�C Ogl� `.V t/ C '•I .�\(Gi ,\yCS . V�p fY.�ilTi� 0 c W �'n C1 int.' :��?
QS QC 001) ,
CIC X10: cam. G:. a
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;Work !complies with written approval from. Structural Engineer and ICBO Evaluation Report #
I'fiereoy certify that I have inspected.all of'the above work, unless:otherwise noted, 'and to,the best`of my ability) have found this work•to comply with the approved
plans„specifications"_applicable building laws. :Final report issued at project completion:;
Inspector: Jack C Min ICB C fi' tt n No .0842216-49 .Contrac or%s�Re�presentative ,
i i2%cze
Copy 1 ,.JCM Inspections' Copy 2 Project Superintendent••Copy 3 "Governing Agency Page of