0201-078 (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
733152 B 3I3i/tT�
,
Date Vii,/ LIZ 'I=:- 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).
( ) 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
performance of the work for which this permit is issued.
-4 J 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:
Camey ST.A'M FUND Policy No. 0460JUNITOODAIS
(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
Code, I shall forthwith comply with those, provisions. f
Date: ! Z ! ,� _ 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 applicaton agrees to, & shall, indemnity
& .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 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 urposes.
Signature (Owner/Aaent) _� `�r _!� _ _ Date
BUILDING PERMIT PERMITS
DATE 11 VALUATION �Io rte, / LOT 0201.078 TRACT
o
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
PCA wwr RFs DFxnAL AssociAnom
DEL MAR FACTiTC OWERAL COMMACx' P
1-� B OX 1060
2533 SOMI -1 COAM' 1IIG3,IWAY ErM 250
LA QU1N IA Chi
C:AkDErT BY 11IE NEA CA 92007
(760)564-9500 OKA 5823
USE OF PERMIT
MSCE 1. AWW 311
SUILDINQ 21-33-50-s 35.513, 55-527,55-539 • VOLUNTARY
3TRUCTU11.Af, MODIFICATIONS
VALUATION 20,000,00 60
EEiTMAfKD C -051C OF COPI917RIUCITION
20dM.00
PTt+'R11 rr F'FE 5trM'MARY
C'•ONST.RUCTION FEY 101-000418.000 $207,00
STRONG MOTION FEE- RESID 101-000-241-000 Z1.fb0
3iii3- t'c.:�#'AL GONS'iRTJ'C'rlgN A1`!Tj 1?I,Altii' C°C"K
$7. U'.�.�!(1
TOTAL PMLWf F. DUH NOW
$709AX)
RECEIPT
DAT J
BY
DATE FI ALE
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Fortes & 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
Partv Wall Insulation
Condensate Lines
Exterior Lath
Drvwall - Int. Lath
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footin
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
I Encapsulation
Final
COMMENTS:
Final
1 Milifv hlMira rrac1
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
4
lelle
DAVE STEAVENS
Inspection Services
PROJECT ;6A
ADDRESS •S'Jq jf;IT, 'S/;C !`w3
owl S'
BLDG. PERNUT #
ENGINEERI,..30 ,..30 SAjasg t r1.G
INSPECTION TYPE
Page —L— of
PROJECT # csP uv L - 011
CLIENT A.A u)[. -*-r 14V*
DATE ,bra -r" AJ a. X w Z
ARCHITECT Ggm- A fl► AIZ-4--4
CONTRACTOR M A 6• V -4A, -f -r► c.
i
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE:To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially oornplies with approved plans, specifications and applicable sections of the building codes.This report covers
-lo Dftdh&work inspected only and does not constitute engineedng opinion or project control.
CERT. NO. 0� 3�1� 3 y CJ' 5u INSPECTOR NAME A JK SAA J i. 45
DATE -v Z'u 0c ;1 '7* L
INSPECTOR SIGNATURe :
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CERTIFICATION OF COMPLIANCE:To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially oornplies with approved plans, specifications and applicable sections of the building codes.This report covers
-lo Dftdh&work inspected only and does not constitute engineedng opinion or project control.
CERT. NO. 0� 3�1� 3 y CJ' 5u INSPECTOR NAME A JK SAA J i. 45
DATE -v Z'u 0c ;1 '7* L
INSPECTOR SIGNATURe :