0105-107 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed ,under provisions of
hapter 9 (commencing with Section 7000) of Division 3 of the Business and
�ofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date. �1 ` �" /Signature of Contractor / r,£ •- v. rr�! ' ?
.
OWNER -BUILDER DECLARATION 1
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 a
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.
( ) . 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 ga q Policy No.TATA t51t ,S �g�t
VLM
(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
1 Code, I shall forthwith comply with thoseprovisions:
Date- +'"?/ a 4" //t i Applicant
�>>�r,<<^y
Warning. Failure to secure Workers'°Corripensatlon 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 f
work is not commenced within 180 days from date of issuance of suchf
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. y r
Signature (Owner/Agent) -'°7' d !•' ±f"JE�/�Z� Date
snwi...a..� - •�� r •' iI k } /�i Y�.{..�'��j\ i:.'w/I.� /J f I.n - , .
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01t* -107 TRACT
7
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR /DESIGNER / EN INEER
C44rl7� 14!5(gL4
Poo
e�
ut'SS.A.�3' •trrl.�ntd. CZ D.7 W
LANURD<.rS�J:`'1't�dSE'l.YLir•8J. 'S'
`;f:rro"fG0 CM -1 E :UANQU9LL4T)PZ
6930 TAW:Y..AANE
NVI) T _11WELLS CA 92210
C.Ni'13.Ir DRAL C�'fY' CA
�S�F'2234J
USE OF PERMIT
S1�Iz PfrtivIMIT 3300 NOT ; 4C,,, TDL HIAX_*K i1t7;.4.S. S, P001,, OR DRIi►',KWAY
APPROA:CK
CUSTOM CGCI+I3 TRUCTION :,ouqm
i 0=1071L FE2 :93.iMMARY
CMIWFIVOCTION PER - 101-000-43a-,000 $1.4"M
FLAN CF''WIK FE01 101-0001.439-310 $1,159.39
I 'R, Y' ,FOOT 101-0t1(W-.39-318 -'s-1,000,00
MbZ,•C:}'JANIC;R,t"„ F89 101-M-421-000 $130.00
WhMTRICA1, ME 101 -000.-42Q-000 $219.84
IDI.a1.idVfaINQ y, 101-000-419-000 $196,30
STRONt d MOVOW FErr - AMC' 101-M-241-000 332.59
C'�P.EI,$'1ING YFF, $20,00
X. ANDPLAN> X.%
,i Z:t�.i 51 P�• .+.�y5 -Y .?w�i
15,410,E
"Q.29e .00
SEP 2 y5 LOo 1 e� °' F v,,W J J .fi.(I:C7 S .Y L HOW
9
CITY OF LA QUINTA
FINA Ce ®EPT
I
tM"V6'C J EY
RECEIPT
DSA%T =,jt,
DATEF D
INSPECTO
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
-APPROVALS
MECHANICAL APPROVALS
Set Backs
s
%r% 3_ �j
Underground Ducts
ti
Forms & Footings -
Slab Grade
%/
(t/
Ducts
Return Air
/
Steel�/j_
Combustion AirRoo
!
O.K. Deck
Wrap
_
� �Ll Oi
Exhaust Fans
/
(�
P
l'" —O'L_ ��
F.A.U.
Framing
Compressor
Insulation
��7. �j�
Vents
v
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath—
Drywall - Int. Lath •U.
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
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
_
Waste Lines /o.:/ (
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral / ���(
I �G 0-1
Pool Cove r
Sewer Connection
`G fN'
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
r
ELECTRICAL
APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
IV U
JOHNSON & NIELSEN ASSOCIATES Svend H. Nielsen
JN Per T. Ron
CONSULTING STRUCTURAL ENGINEERS Wen Y. Lin
647 N. Main Street • Suite 4-81 Riverside • CA • 92501 • (909) 686-5122 • FAX (909) 686-6752 Lonnie P Mount
L O S /� N G E L ES Steen T. Thomsen
RIVERSIDE . IRVINE PALM SPRINGS Jackson K. Wu
January 4, 2002 J & N Job No. 25-696
Curtis Richard Shupe - Architect ;
73-255 EI Paseo, Suite 15 .
Palm Desert, CA 92260
Re:- 78-- L a S�The Citrus (Bouchier Residence) -
'ZLa Quints, CA
s
Dear Curtis,
This letter is to serve as written confirmation of,the complete framing inspection I made at the
above address on January 5, 2002. Based on this visitation, it is my opinion, that the
complete framing is in compliance to plans and specs.
If you have any questions, please feel free to call.
Sincerely, QA-FESSlp
r;
Amfo"
N0.3834
EXP. 3-31.2004�
Loe*P.Mount, S.E. #
P
JOHNSON & NIELSEN ASSOCIATES OF cAv�F°�
Consulting Structural Engineers
~ E:\WPDOCS\0-FORMS\INSPECTN.LTR\FRAMINSP.696
Lop