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04-4369 (AR)rt i 4 P.O. Box 1504 78-495 CALLE TAMPICO LA QUINTA, CALIFORNIA 92253 BUILDING PERMIT Application Number . . . Property Address . . . . APN: Application description Property Zoning . . . Application valuation Owner ------------------------ BILL POOLTON *NOT ON FILE LA QUINTA CA 95523 BUILDING & SAFETY DEPARTMENT (760).777-7012 FAX (760) 777-7011 INSPECTION REQUESTS (760) 777-7153 04-00004369 Date 6/01/04 80444 HERMITAGE 762-200-017-21 P -000000 - ADDITION - RESIDENTIAL LOW DENSITY RESIDENTIAL 12152 Contractor ------------------------ EDWARDS CONSTRUCTION, BOB 79920 FIESTA DR LA QUINTA CA 92253 WCC: PREF INS WC: WKN1090403 01/01/05 CSLB: 684857 03/31/06 CCC: B ------ Structure Information 156 SQ.FT. ADDITION ----- Construction Type.. TYPE V - NON RATED Occupancy Type DWELLG/LODGING/LONG <=10 Flood Zone . . . . . . . . NON -AO FLOOD ZONE Other struct info . . . . . CODE EDITION 2001 CBC FLOOD ZONE NO FIRST FLOOR SQ FTG 156.00 -----------------------7---------------------------------------------------- Permit . . . . . . BUILDING PERMIT Additional desc Permit Fee . . . . 144.00 Plan Check F O '3.60 Issue Date . . . . Valuati b 152 Qty Unit Charge Per BASE FEE 11.00 9.0000 THOU BLDG 2,001-25,000 ----------------------------------------------------- Permit . . . . . . ELECT - ADD/ALT/REM Additional desc . . on 00 00 Permit Fee . . . . 30.21 Plan Check Fee . . 7.55 Issue Date . . . . Valuation . . . . 0 Qty Unit Charge Per Extension BASE FEE 15.00 156.00 .0350 ELEC NEW RES - 1 OR 2 FAMILY 5.46 13.00 .7500 PER ELEC DEVICE/FIXTURE 1ST 20 9.75 ---------------------------------------------------------------------- * ------ P.O. BOX 1504�� VOICE (760)777-7012 Taf 78-495 CALLS TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: m q 11369 1 Date: 6 -/- O Y Applicant: Applicant's Mailing Address: ArcMr eft orT�g1'� ArcMt or ngig�Ir's ddress�_,` A `Z-- Lic. No.: BUILDING PERMIT DECLARATIONS LICENSED CONTRACTOR'S DECLARATION I hereby affirmundergqqqenalty 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 Lim s in full force and effect. License CIa s _� License No. Date (9 0 04 Contractor�i()K� r OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): U 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 and Professions Code: The Contractors' State License Law does not apply to n owner of property who builds or improves thereon, and who does the work himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.). U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to the Contractors' State License Law.). U I am exempt under Sec. , B.& P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: _:ha ve 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 f the work for which this permit is issued. I 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 sued. My workers' compensation insurance carntr ar�dpolipy�ur�ber aje Carrier D c� Lc S fr 2A+Mi Policy Number W K t l \6V `1 ` fy _ 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 Calif.I'D 'ree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, 1 shall f rthwith comply with thos C Date (,( G Applicant C G� WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($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. CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address APPLICANT ACKNOWLEDGEMENT IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Ouinta, its officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit. 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 tion. I certify that I have read this application 8nd state that the abo a info ation is correct. I agree to comply with all city and county ordinances and state laws relating to building constru9c_tio , d hereby authorize representatives of this co , ty to r u nth entioned prop for inspection purposes. Date `� ��Q Signature (Applicant or Agent): r Page 2 Application Number . . . . . 04-0000436.9 Date 6/01/04 Permit . . . . . . MECHANICAL Additional desc Permit Fee . . . . 24.00 Plan Check Fee 6.00 Issue Date . . . . Valuation . . . . 0 Qty Unit Charge Per Extension BASE FEE 15.00 1.00 9.0000 =------------------------- EA MECH APPL REP/ALT/ADD 9.00 Other Fees . . . . . -------------------------------------------------- . . . . ENERGY REVIEW FEE 9.36 STRONG MOTION (SMI) - RES 1.21 Fee summary Charged ----------------- ---------- Paid ---------- Credited ---------- Due Permit Fee Total 198.21 .00 ---------- .00 198.21 Plan Check Total 107.15 .00 .00 107.15 Other Fee Total 10.57 .00' .00 10.57 Grand Total 315.93 .00 .00 315.93 TANDY'S INSPECTION INC. PO BOX 13766 PALM DESERT, CA 92255 SPECIAL INSPECTION DAILY REPORT OFFICE/FAX 909.769.9717 PAGER 760.776.3339 TYPE OF INSPECTION PERFORMED SAMPLE INFORMATION rl--J3 bK SAMMPLLE SLUMP TIME IN MIXER PHYSICAL�°DRESS PERMIT NUMBER t4 L4CQ LOCATION JOB NAME' OF STRUCTURE L la� - 4"lL4 WELDING INFORMATION - ARCHRECT A ENGINEER b • � i�Q �.� GENE ONTRACTOR SUBCONTRACTOR • DESCRIPTIONOF •- SAMPLE INFORMATION SUPPLIER TICKET NUMBER MIX NUMBER TIME SAMPLED AIR TEMP SAMMPLLE SLUMP TIME IN MIXER LOCATION BRIM• WELDING INFORMATION - PROCESS WELDERS NAME • � i�Q �.� �• .rima.. -�sa� a • • I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK, UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS & APPLICABLE BUILDING LAWS. KTIN Qh3-�41 CTOR NA lea -� INSPECTORS CER ION Y AND NUMBER SAMPLE INFORMATION SUPPLIER TICKET NUMBER MIX NUMBER TIME SAMPLED AIR TEMP SAMMPLLE SLUMP TIME IN MIXER LOCATION WELDING INFORMATION - PROCESS WELDERS NAME CERTIFYING AGENCY AND CERTIFICATION NUMBER I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK, UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS & APPLICABLE BUILDING LAWS. KTIN Qh3-�41 CTOR NA lea -� INSPECTORS CER ION Y AND NUMBER � 5- I'm 0 7-:iC'411 TANDY'S INSPECTION INC. PO BOX 13766 PALM DESERT, CA 92255 SPECIAL INSPECTION DAILY REPORT OFFICE/FAX 909.769.9717 PAGER 760.776.3339 TYPE OF INSPECTION PERFORMED t ,O o x K SAMPLE INFORMATION DATE (o " / 8 , PHYSICAL ADDRESS (30�� i�1✓72/�'1 TRS' .— �� u r PERMIT NUMBER O �{ - 41{ 3 (P `/ JOB NAME Po t4 L �T-o^/ eRc.5. @ P�r,4 toc's� TYPE OF STRUCTURE ARCHITECTENGINEER Ro6EF r A, 017cW1=©gl 15 R I P/IA-)A RAYAtJ A GENERAL CONTRACTOR 8015 W piAle..0j t�jo Ns 7- . SUB CONTRACTOR I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK, UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS 8 APPLICABLE BUILDING LAWS. INSPECTORS SIGNA l L ! l 3 Z -4(e INSPECTORS CERTIFICATION AGENCY AND NUMBER SAMPLE INFORMATION DESCRIPTION OF WORK INSPECTED TICKET NUMBER MIX NUMBER SAMPLED AIR TEMP MPLSTEPPE SLUMP TIME IN MIXER LOCATION 8�. X.-*?,5t'L7 f&)IrV EX1ST-iiv& V,o,0, 967;3 A -Z c0 ��r, � � o J'Af M CY-I sTfxDG WELDERS NAME A 4,4, 1 la E, A. S, d ,l ` .2'/'� LOA4( 6 A -it700 71 /V6r 2.' 6pl LDA16: I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK, UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS 8 APPLICABLE BUILDING LAWS. INSPECTORS SIGNA l L ! l 3 Z -4(e INSPECTORS CERTIFICATION AGENCY AND NUMBER SAMPLE INFORMATION SUPPLIER TICKET NUMBER MIX NUMBER SAMPLED AIR TEMP MPLSTEPPE SLUMP TIME IN MIXER LOCATION WELDING INFORMATION PROCESS WELDERS NAME CERTIFYING AGENCY AND CERTIFICATION NUMBER I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK, UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS 8 APPLICABLE BUILDING LAWS. INSPECTORS SIGNA l L ! l 3 Z -4(e INSPECTORS CERTIFICATION AGENCY AND NUMBER n TANDY'S INSPECTION INC. PO BOX 13766 PALM DESERT, CA 92255 SPECIAL INSPECTION DAILY REPORT OFFICE/FAX 909.769.9717 PAGER 760.776.3339 TYPE Of INSPECTION PERFORMED DATE PHYSICAL ADDRESS PERMIT NUMBER JOB NAME TYPE OF STRUCTURE ARCHITECT ENGINEER GENERAL CONTRACTOR SUB CONTRACTOR I DESCRIPTION OF WORK INSPECTED SAMPLE INFORMATION SUPPLIER TICKET NUMBER MIX NUMBER SAMPLED AIR TEMP STEPPE SLUMP TIME IN MIXER LOCATION WELDING INFORMATION PROCESS WELDERS NAME CERTIFYING AGENCY AND CERTIFICATION NUMBER I HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE NOTED, AND TO THE BEST OF MY ABILITY I HAVE FOUND THIS INSPECTORS SIGNATURE WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFICATIONS 6 APPLICABLE BUILDING LAWS. CC: WSPEC TORS CERTIFICATION AGE NCYAND NUMBER