0201-085 (BLDG)LICENSED CONTRACTOR DECLARATION
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?1315 i3 ;' 3/3163
Date Signature of Contractor Z/
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors
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
perfprmance of the work for which this permit is issued.
6) 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.
STATE FUND 046011.4411100MIS
(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 370q of the Labor
Code, I s.h4llfO�i�i with comply with those pro4isions.! r f
Date: / f 1 i Applicant ' (% •t' j.
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 agre¢s to, & shall, Indemnity
&.hold harmless the City of La Ouinta, Its off icers,'agents and employees.
2. Any permit Issued as a result of this application becomes null and Vold 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 Pis City to enter upon
the above-mentioned property for Inspection, purposes./
r
tt ` �
Signature (Owner/Agent) `r /" �•R A %� Date / / BUILDING
1-
PERMITPERMIT#
DATE VALUATION LOT 0201. (JOS TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PGA WWUSIMEbI'ITAY., ABS=AU014
OM, MAR PACNIC GEN RAL CONTRACTOR
PO..MX 1060
2533 SOMI COAST HIGHWAY MYR 250
LA raY11.WA GA
GAlRDIW IIY THU.SR-A CA 92.0,17
Q60)56-4-9500 C1a'IB 5823
USE OF PERMIT
BUILL)INU 28 - 54.961; 5d:9i",'5d-003, 54.077- VOLUNTARY
:i`I`RUCTURAIL MODIFICATIONS
VALUATION 20,000,001:8
ES'TAIAM C06I Of' COINSIRIX'TION
20AM0.00
PER.1!aTT['FEE SUAMARY
CONSTRUCTION PEP. 101.000-418.000 $207.00
STRONG MOTION FEE PX51r1 101-000-241-000 $3.00
u
. A
J�f�J 31 g� k :'
' Rods �@iii Yd. e�;ah.A'�t••. '^a
St1 TOTAL COMTRi Tr°17.ON AND 1'T 4N CHECK ' :
5209.00
IWAL PErMYT FEES IMM JRQW
Sai19,Ut►
RECEIPT
DATE
BY
DATE FI LED y
INSPE R
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 8 Controls
Party Wali Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final Z
BLOCKWALL APPROVA S
POOLS - SPAS
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 Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final:
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
ti Utility Notice (Perm)
COMMENTS:
f�r�
r
DAVE STEAVENS
Inspection Services
PROJECT Sl;eA We -sr - IL c G t LJ 05
ADDRESS.'!` 41 • cil
t117!''5 i.U,Jt 1St ACs 2.9 ZOO 2
6LO6 101AS
BLDG. PERMIT #
ENGINEER N+J SA J�lrr. NC.
INSPECTION TYPE
Page of
PROJECT # 2 00 (� Z " v `f
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CLIENT ?%-44 t �:,7"' N U
DATE / T •Tu L Y Z v Z.
ARC1=CT 6v C. J11 d c*4
CONTRACTOR J - PO AA 1:W- f,= •L
INSPECTION REPORT
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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
locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO.419) S��7 INSPECTOR NAME
DATE / *7 .,7u .t--( ;too Z � INSPECTOR SIGNATu' at.i CJ�1
DAVE STEAVENS
Inspection Services
PROJECT -Wr\ U) a -S'r L- f eX AM3
ADDRESSES •0 2'? vd -1, :5q. 51$,3' cf4 f
BLDG. PERMIT #
ENGINEER,, . W Sd 4,0 if. ! -J C .
INSPECTION TYPE
Page i of f
PROJECT # •7%o" Z - &J
CLIENT za c 37- t4yr4
DATE I (e ..amu LY 2 cx-"Z
ARCHITECT 6J. dA AA -'C-4
&
CONTRACTOR 4. 0?,04 4 1' c. -r ", 9
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
0jsubstantialtyo� with approved plans, specifications and applicable sections of the building codes. This report covers
A.he,tar:�#i rk inspected only and does not constitute engineedng. opinion or project control.
CERT. NO. Qt?5Y 3 q g ` S-0 INSPECTOR NAME �r f► J
DATE A. .ado a
Y L INSPECTOR SIGNATURYE`e . c�