0012-064 (RPL)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
fi�ER95 C53 fa+1l3i?r`a4
Date f 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. 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 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.
(,e) 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) nsurance carrier & policy no. are:
Carrier Policy No.
STATE FUND
I3i6S�a-UD
(This section need not be completed if the permit valuation is for $100.00 or less). '
O 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 withthose provisions.
Date: ;► —1'"- •r -14Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees:
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions" and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &.shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) -�- L �— r• "" Date
BUILDING PERMIT PERMIT"
DATE % VALUATION LOT W124)64 TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Q4.380HKRI . IrAVIIE,
74-'725 JONID 1V]: 4A
LA QUI14 A, CA 9225.E
PJAUM DESF T CA. 92260
(760)340.900+0 MIR 53P,G
USE OF PERMIT
FOOL MID/0R EPA.
PO0L&Sf1A&BBQ&Y1R.9PTR Cltd�i''�A�dl�fZ:hl•_18•i3�}Sf,A.LAd2.(UIaJ�Ai2d211?'>~YS'
5�l.�'a%� �C 3Ii PR.�Sf".E. J1.T ply Yi�:1TCS1d. 1139P�:fi'P!'CAIR, P�J:�i., Lt�t.Rlf?)!�C$I�i°�
101C,"LO ;I RE, IS NOT );NCR. DED IN THIS PERNlirk.
POOL AND/OR SPA 1.3
EST,A,°X��oC3 COST Or, CONMU(MM
"PERK'i' "M Sd.7A13 AIAIRY
CLMI CHWX M1 011100
CONSTRUCTION ME3.€)7-fIUQ �I�f•d3iJi� �Rga.tYa
NIEC IAMAL FEI, -- POOL 101.000,421.000 524,00
KI.MTRIC:ALYZE--'POOL 110.1-00020400 j�i5.4a
PLUMBING FPS - - POOL 01RM)0419.000
0'8-`L`OiIAL C:C9ARSMI:uMOH WD PLAN N CIM, C
$393.00
F s
00
pr v `9 7 (. 5 X973` �Iye�I.Uyr-P�,AW
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V". Do
RECEIPT
DATE
B1r° r
DATE FINALED
.INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond /o-
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 % p
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:
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
3580 Condalia Ave.
Yucca Valley, CA 92284
(760) 365-5045,
TYPE OF
❑ REINFORCED CONCRETE
STRUCT. STEEL ASSEMBLY
❑
INSPECTION
❑ POST TENSIONED CONCRETE
ASPHALT
'OTHER��1_.V�
`
PERFORMED
❑ REINFORCED MASONRY ❑
FIRE PROOFING
1
JO L ATION
REPORT SEQUENCE N0,
TY E OF STRU TORE
PERMIT N0.
j�,T
DAY OF WEEK
M
ERIAL DESCRIPTION
ARCHITECT
P CTOR
HRS. CHARGED
1HRS.CHARGED
-
•^ti
ENGINEERASSISTANTS
INSPECTION
DATE
GENERAL L �) \A
CONTRACTOR (,
SUB
CONTRACTOR�/ `�
c,� l
L i")PN ,I Vln
N
i/1
9
COPY SENT TO CLIENT
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.
CONTINUED ON NEXT PAGE ❑
PAGE OF
NATO E OF REGISTER INSPECTOR
OF OPIUM] REGISTER NUMBER C/`