0209-239 (BLCK)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cl W Professionals Code, and my License is in full force and effect.
G � ch License # Lic. Class Exp. Date
W/. "0 435033 � C � fYt�' �' : Q;i'JYP,.0
r Z � P Date '� ,. •7 Signature of Contractor
Apr` f
J U Q OWNER -BUILDER DECLARATION
HW
I hereby affirm under penalty of perjury'that I am exempt from the Contractor's
CL
0) 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).
c") () I am exempt under Section , B&P.C. for this reason
0 Date Signature of Owner
0)a Q WORKER'S COMPENSATION DECLARATION
p CC I hereby affirm under penalty of perjury one of the following declarations:
In H O O 1 have and will maintain a certificate of consent to self -insure for workers'
X W Y= compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q *J) I have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H- permit is .issued. My workers' compensation insurance carrier & policy no. are:
ZCarrie'ATF KYND Policy No.
CIS
r` d
g (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 prov)sions of Section 3700 of the Labor
1/6de, I sh II fo hwith comply with iloprovisions.
' Date: ''•f t Applicant-,'/ l
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 applicator 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 Clty; 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.
i Signature (Owner/Agent).' �� i �--,r" Date%;�">/ 1. �.
BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
d.()iY f:AT✓r "drds� w ,fit
JOB SITE APN
ADDRESS bio—'ij FiTfI TI! �Y.cR�i�
OWNER CONTRACTOR / DESIGNER / EN &NEER
1A Qi.71NTA i X)N{aRi;GAM N E3`t 012? R. C:Cjl+iYJ.7.�Ct..f!"_MON .ilii:'.
46.3001: itTMJF'.t1,1,W.7RQAn 57.E7029PAS N1331YWY-20l
3.:AQULi<i A CA 9125:5 Ti'MAVALI1,Y, CA .92294
f;%tJo).34..i imt3G:►'I dam' ;LA 2 5 WZ
USE OF PERMIT
GENERAL. Bi:TH.-PATO
97,' Lr V COA111114 3TtOt1 C RZTfiANJNC)'W1'i'1-14' GARDa h2 ;h1.AL.1, PER.
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KS11MfA';C11M (.`)FV OF C011,ti'>!2.1Ai✓'".10M 44,125,1111
� LT"I�N {titAM-f1L ci1iffrRC It $2.`.r2.0()
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RECEIPT (DATE I*B�i ID11 /AL�C;r1t% IINBPECTCR
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
SLS OCi`r WALL APPROVALS
POOILS - SPAS
Steel
Set Backs
Electric Bond
Footings
- '.o
Main Drain
Bond Beam
Approval to Cover
SsoG •
Equipment Location
B 4p&
Underground Electric
. 2j4.97r 1j
Underground Plbg. Test
final
72
Gas Piping
PLUMBWG ROVAL
Gas Test
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
Final
Utility Notice (Gas)
ELLECT=AL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receotacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
r,
fiACKER ENGINE-,ERINGI N C 0 R P 0 R A I E D
May 18, 2003
Building and Safety Dept.
City of La Quinta
78-495 Calle Tampico
La Quinta, CA 92253
Re: Kingdom Hall Bldg #1
Dear Sir or Madam:
I have reviewed the structural components of the above referenced project. I am
satisfied that this structure complies with the structural design as shown on the approved
plans. Please call me if you have any questions.
f
Sincerely,
Michael D. Hacker, P.E.
Z9 tw ,is(" 0
00. gavo
68-487'Hlghway 111 • Sulte,43 • Cathedral City, CA 92234 • (760) 202-1800 a Fax (760) 202=8267
engheer@hackerengineedng.com
JCM.Inspections
39725 Garand Lane Suite F
Palm Desert, CA 92211
INSPECTIONS Phone* 760-345-5554 - Fax: 760-772-3895
LTM__M"MJ
INSPECTIONS
` WELDING INSPECTION REPORT
Date:'
Project Name: Project No:
LA QQ /,..r -r -A 46n/770,J
Project Address: City:
e,� 3cr0 /� c.�Nci �/}c +.mss LA Qv r ,_-tom , c,4,
AWS IBC
E�D 1.1 E] Title 24
❑ D 1.3 D Other
Q D 1.4
Client: Sub -Contractor: /
r�/<%1C�[r ck�iG �T INS? n i.J Li
General Contractor: Architect: Structural Englneer:
S",fe_.N_Yz—
Description of Work Inspected: �L
Shop
Field
Unresolved Items:
None-
[:]-None-
❑See Below
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Process
Welder
Cert on
File
Electrode
Detail(s)
Location/Comments
Yes
No
Type
Size
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hereby certify that I have inspected all of the above work, unless otherwisenoted, and to the best of my ability I have found this work to comply with the approved.
plans, specifications applicable building laws. Final report.issued at project completion.
Insp� ven T. od S Certification No: 03100321
Contract ep a �
. . . _: tl
Copy 1 JCM Inspections Copy 2 Project Superintendent Copy Governing Agency Page / . of