0311-215 (AR)CO
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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
Professionals Code, and my License is in full force,and effect.
License .# Lic. Class Exp. Date
17ate� Signature of Contractor
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. 7644, Business & Professionals
Code).
( ) I am exempt under Section ,.B&RC. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION.
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'Seotion 3700 of the Labor Code,, for the
performance of the work for which this permit is 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 carver & policy no. are:
Caner STAT° FUND Policy No. SIM. 169
(This section ,need notbe completed if the permit valuation is for $100.00 or less),
( ) I certify'that in the performance of the work;forwhich this permit is: issued,
I shall not employ any person in any manner so as tor become subject to the
workers' compensation laws of California, and agree that if .l should become
subject to the workers' compensationprovisions of Section 3700 of the Labor
'de, I shall forthwith comply with those . rovi ons/
Date: T� Applicant
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 fo°the,4uilding
construction; and hereby authorize representatives of this City to enter upon
the above-mentioned propertyfor inspection purposes.,
Signature (Owner/Agent).-w- '�'r r� � -- .'Date/ . . e
BUILDING PERMIT PERMIT#
DATE I VALUATION.;79�.1(3 LOTTRACT
JOB SITE
APN
ADDRESS-�>�,H.�►Q�IN
OWNER
CONTRACTOR'/ DESIGNER / EN (NEER
XAi l'i:lY A RzCM'1.1.PD MUT1M
t 1?"C,r..F1J �teJ t3�T i l�iac} Lt�Iv
78-269 TIArrMIT A
5775 1ic"Fl.IitU, WAY
LA. QU'13dTA CA 922S3
.YORDA Ub71)A CA 9 2RR'S-11
(714)993-3320 ' eff 03819
USE OF PERMIT
REHIu-24MAL)POT)rrrON
47 SF [WINO ROC?tal ADDITION. CBC..
Ar,,.t31TiON 47.00 9F
.,,. VALUATION 6,947.00 LS
X97T1uX.AM) COST OF (,10J7MZiiG1 0,P7
PLAN AN CHICK FRY, 101-000-439-316 57610:5
CONSTRUCTION FEE 101-00%1"18-000 $11700
ELECTWCAL VEE 101-000.420-000 513.7x°
STW NCI MOTION FENT-"RFSIQ 1,01-000-241-000 Q•93
su7drTC1m, COwE7'.CRCfcmtaN Am-) PT..N,A3 C1; FcK
$2 12.17 3
LESS PPS -PAID FEES
$0.00
j
iJ P:ici it 1 ! EES MIEN ow
$21.2.1
0 2 2003
CITY OF LA Q0,drD -4 std
FIs ANCE DEPT
RECEIPT
DATE
Bey �'�;
DATE'FI O
INSPECTOR
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
_
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
ELOCKWALL
APPROVALS
steel
Set Backs.
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground.Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas rest
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment.Enclosure
Shower Pans
O.K for Finish Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
-
"
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)
s-
1
SPECIAL INSP.EGTION 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
❑ POST TENSIONED CONCRETE
❑ REINFORCED. MASONRY.
❑ STRUCT. STEEL ASSEMBLY
❑ ASPHALT
O FIREPROOFING
O
THER
JOB LOCATION
_ cZ 6 A
LAREPORT
Qj
SEQUENCE N0.
TVP OF TgyGTVRE � � �
PENtrJJi�NE� `
� 0
DAV OF WEEK
MATERIAL DESCRIPTION
AppC,,� ITECT
pCQ-%4 CTb, U"U JAN
I pT
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HRS. CHARGED
ENGINEER
ASSISTANTS
NRS. CHARGED
OASUB
TEEM
GEHE R / 1 dL1 ^'
CONTRACTOR
COPY SENT TO CLIENT O
ONTINUED.ONNEXT PAGE O
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. 1 HAVE FOUND THIS WORK'TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
ATURE OF R TIERED INSPECTOR
DATE OF REPORT REGISTER NUMBER ^T-