0201-084 (BLDG)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
7 X15 13 3/344).3
Date Signature of Contractor I r
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&RC. 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.
(.) 1 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 Policy No.
STAIH� KIM) N603VIAIT000415 i:":_
(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 becoine
subject to the workers' compensation provisions of Section 3900 of the Labor
Code, I shall forthwith comply with those provisions, / J
Date: 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 lilt 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 perfor6e4 under or pursuant to
any permit issued as a result of this applicaton agrees�fo,,.& shall, indemnify
& hold harmless the City of La Quinta; its officers, agents agd'employees. ;
2. Any permit issued as a result of -this application• becomes nufl 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. 1 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.
Siqnature (Owner/Anent) ? r' ' ! f i % °� Date''
----------------
BUILDING
-------------
BUILDING PERMIT PERMIT#
\/1 ,
DATE VALUATION LOT 02411-064 TRACT
JOB SITE
ADDRESS u� [ %�
—0F
APN
1/u?XTVr NF
-
OWNER
ICONTRACTORIDESIGNER/EN INEER
KIA WEST RFM DENTI AI., ASSOCLATIC)''N
DIM— hIAR. PACOC t3FXCIt.P , C°OWRACTOR
PONXXl060
253320ITTHCOAi�OT13101TWAY:iTFl Z.10
IsA Qulwry, CA
CAP1111rBY P10', S*F.A CA 517007
(760)564.9500 t:Lil..lt ' 823
USE OF PERMIT
Mi:7C1I.7..1�;•ii?.•C)1.7I1
HU1:-,f. IND xl , _%4-043,54-063, M-071,54-039 • VOL,11NTAkY
STKIIJOTilRAI, MODIIrICATIONS
VAIXAZ IOW 6tl,1100.00 1 a
X1;XD 4A1%a) COKU 010 CON. tT 'RUUJ..Sc)N
29M.00
PEWIT FEE SUMMARY
CONSTRIA,1TION F N . 101 -000-418-000 E20,,011
snwNa MOTION i!rO,- kESID 10140j-241-0100 V.00
sui -TCy1' . CX)k srrRt7G"'l`nI1 w.) P•i.Ao ci3l•`CK
LIM,) PRE-PAIDOW
TO'iAL It ERMIT 1rFXS l:)nL E PION
RECEIPT
DATE.
/
BY
DATE F ALE
r6—d
IN" PEC
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION ---j
DATE TINSPECTOR
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
Pa 5y Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 11 10 7— 1 k-�
...
. ..
Pobf:t�-, 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
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'.Cpver
Sewer Connection
-1ficapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENT�
//;rA/
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures;
Win Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
DAVE STEAVENS
Inspection Services
Page ( of I
4 Owl .
PROJECT _, A t,0 c E- PROJECT # .2
ADDRESS 5-'_' • QP,'4 Q'7 r � '". QqY 5 CLIENT _iGA Q Z -,n T
r
L.4 J DATE 1,A o 4! '9 c ac> �-
BLDG. PERMIT #
ENGINEER Iu.,3� SAJ it r= 1 ,,j C
INSPECTION TYPE
ARCHITECT (mc_QA
A
CONTRACTOR .��� c: rkw o: t�)aci/- i c
INSPECTION REPORT
�? �' • i f i to A J J �'(`r -
r
A K ! "4A "i .5.-7- Z4 ,zTcrz . ��%&,�� -Ja' tily 'VAIZ."1e
t r r
d
r4 A yJ ti Y.) e.'/
PA)oq t L it7
w
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially complies with approved plans, specifications and'applicable sections of the building codes. This report covers
the locations..&frthe�work'inspected only and does not constitute engineering opinion or project control.
CERT. NO. INSPECTOR NAME ---��
(Print Clearly)
DATE w.�U v ` <;0 INSPECTOR SIGNATURE
Page of 1
DAVE STEAVENS
Inspection Services
PROJECT �(-, Ay.) L i U:"'. t'. e .c_o� A PROJECT # r,1 c> g ;2 — y
ADDRESS f:5 e ;`A .'J 11,
BLDG. PERMIT #
ENGINEER .L -,+.Z,.) � enc
INSPECTION TYPE
CLIENT�`�a,1a:.
DATE It --rt-kL-,q '-1 coo Z,
ARCHITECT ' U4OL;A A A2 c A-1
CONTRACTORe-L tAli,w Y•��,r-':
INSPECTION REPORT
�A�%` j lv' C�e- E ly pA Rje Lr %"C-F°� C-;
..���`_ o i yA 1,t r'��.A5 - -7- �-��°� b.�F-� A��
• r r ,
�.JL""i .. 1 "i �, i.^.wfivv+ i:�L.. 1` �..�✓C:.i=I'� t�ff�G��t'• it✓fi�4r r-.�+�� t,.
7 it.�
t Y �
( 4 (o IS 'ZaiVVk , , ) P. r(� 7.0 C.a:/1 n 1 (— i r7-"- ri 1 i.$. - C .. t:;� t. G.w
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
the locations of the�work inspected only and does not constitute engineering opinion or project control.
CERT. NO.
-.`" `' c(
INSPECTOR NAME V �.r rN
='
DATE
'`�
INSPECTOR SIGNATURE
(Print Clearly)