0201-081 (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
�a�isla Ell : r X131!
Date ' �=' Signature of Contractor
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).
( ) 1, 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
performance of the work for which this permit is issued.
V ) 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 3T1!TF, tr'0HO Policy No. M601UMT0004413
(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 3700,9f the Labor
Code, I s all forthwith comply with those•provisions.(
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 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 appllcaton agrees to, & shall, Indemnify
& hold harmless the City of La Ouinta, 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 160 days from date of Issuance of such
permit, or ceasation of work for. IAP 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./'%(
Signature (owner/Agent) I t Date/,j '
v�
BUILDING PERMIT PERMIT#
DATE VALUATION LOT Ij201-t-Mi TRACT
t� Jj(tf{
JOB SITE
ADDRESS
APN
-
OWNER
CONTRACTOR / DESIGNER / EN INEER
PGA WM R1;.SiI9F-1,? 1IAL AS&XI&W 14
DEL MAS. i .f :CW10. CIFNERAL CGONTR CMR.
PO I:0X I(XO
3533 50I)IT1I 00AOTIHIS11WAT M 250
1.,A C21.1:i1' -A CA
C:fi 1Xti+19131 "f 9 31?A CA 92007
(-160)564-9500 C'31A. •5823
USE OF PERMIT
13UILDINO 24 • 35469,55-291, 55-293, 55-3,05 YULUNITA1LY
STRUCTURAL MODIFICATIONS
VAI:UATKYN ZU,DIt0.0p LS
ES.tM1TED COW OF C.'ONYMI I171701q .
2U,0t1tJ,93t1
la'1f;.'R.&Trr FEE BITA MARY
CO)MA.l1C1104 MH 101-000-4113.000 $309.00
T RONO MOM-hq IEE - RRSID 101 -000-241 -OW $2.00
Ih' f �e�ii a C:
SITTI.-TOTAL CUM�I I U'C°TAC72J ANLL 1R�I / i tii 4
$209.00
Ly -so 'PRE -YAW Mo
$0.00
TOTAL PERAW 1 KE . I'UIE INOW
RECEIPT
DAT
I�?t r ''1
BY r+
(/�Z1
DAT F ALED/
�
INSPEC
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
OX 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
17
Final
Final X4
BLOCKWALL APPROVALS
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
Elactric 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)
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
4,Final
,101fility Notice (Penn)
COMMENT S:
s'
DAVE S'ITEAVENS
Inspection Services
PROJECT P&A
ADDRESS'S- 5 '�-3 .1&� akv,(i
{ I myS'c:D . a ty tAL iGn a 41 1\ i
BLDG. PERMIT #
ENGINEER SA jo, Q..
INSPECTION TYPE
Page I of k
PROJECT # C -P C- a r 0 9,
CLIENT
DATE a - L.I s2 �-d O Z,
ARCHITECT 6,OL A Ar? C. A
CONTRACTOR-J--�C- t.._ m rq sem.
INSPECTION REPORT
tL t t. 1° •I I M- 'a e torr4t- rl 571ef1P AtL w
i
M
Ste. '57 r7. 1 / o t i "� G. if. P!'! LJ Ai i_. ".N i—f -7, >t'
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 fhe`work inspected only and does not constitute -'engineering opinion or project control.
CERT. NO. � 71yl W ' =. INSPECTOR NAME E' A I
(Print Clearly) ,
DATE L- ? v �i_ INSPECTOR SIGNATURE