0301-061 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licens4d-under provisions of
Chapik 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
'74 11
D74 '03
2- Signature of Contractor
Date
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ). li 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)..
O I am.exempt under Section B&P.C. for this reason
Date Signature of Owner'
WORKER'S COMPENSATION DECLARATION
I hereby affirm ffirm under penalty. of perjury:one of, the following. declarations:
I hay 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.
J(:/). I have and will maintain workers' compensation insurance, as required by
Se'ction '370b.of the Labor .Code, for the performance of the work for which this
permit is issued.sMy workers' compensation insurance carrier & policy no. are:.
qOpr WkATF MIA Policy No.
(Thig section need not be compl6ted'if the. permit valuation is for $100.00 or less).
O I cert.ify.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, 4f I should become
subject to the Workers' conripensation,pr�visionsof 'Section 3700 of the Labor
Code, I shall forthwith -comply with those provisi6ns.
Date. % r, .jam Applicant—
Warning: Failure to secure Workers" Compensation coverage is unlawful and
shall subject an employer to criminal ., penalties and civil fines up to $1 oo,6ot),� in
addition to the'cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.'
IMPORTANT Application is hereby made to the Director of Building and Safety
for •.a permit subject to the conditions and restrictions set forth on his
application.
l.-Eachperson upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees We & shall, indemnity
& hold harmless the City of La Quinta,.its officers, agents and employees.
2. Any permit issued as a result of this application becomes null land void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to Cancellation.
1 certify that I have read this application and State that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentiohed property forJnspectin—urposesi
qinn�fi era 'ir)%mnarlAnanfi ie nn t P"* -X <
BUILDING PERMIT PERMIT /t
DATE VALUATION ,4ogw LOT a TRACT
JOB SITE
ADDRESS 49.43% �u 60,HQUIS
APNTCADOR ani :cP las
OWNER
CONTRACTOR/ DESIGNER/ EN 6 I NEER
111) XMI-113,;CT D. V auopumrl
BRARKS COVISIXIXTTNON
O'X IT) 6
L fie, Quwrx CA 974753
LA(:fjMTA. CA 922513'
USE OF PERMIT
UTMLE FAMUZ X)Wff �11WG
,-Sfyll - LOT 6 PLAN 34 2 PEPMIT D,0H3 NOT INCLUDE, OLCV-'r. WALL3,
4 0QJ', SIPA.011 DRMWAY APTROA1011.
CUSTOM MRSTRUCTION ANWO OF
PC, RGHPAY10 44&605Y
EaTUATED (70gr ON'COBTFMW�00M
295140 M)
con'Twell'or, yv!g
ass' CHECK ftf,' Ar ..'r,
MECMINICALF89 I o I kakl 312410
"r-1 WITRIC-Ablere 101 -00("20-00o MI i•.$
P14NABANO Va. 101.0,00 CUR -000 RUM
STROWO Mar) ON. fmg a =113 Vt�4
(IM0010 PRE 101-900-423-000
.DEXEWPXIR IMPACT 'Zip $2,40, W
IMF IN PUBLIC PILAIOZO 'Rort 270 000-4-01-0100 $23815
FRM-IOTAL COMMUC10014. AND PLAW CRWX
LU 3B !Yf*,-%VAU) PERMS
$0.00
RECEIPT
DATE
1b, -24",
BY
DATE FINALED
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR'
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Al -2 3 - 3
Ducts
Slab Grade
-
Return Air
Steel
Combustion Air
Roof Deck
- / - j
Exhaust Fans
O.K. to Wrap
- 3
F.A.U.
Framing
7= /
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
77
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 I
I
Gas Piping
'
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
_
Plumbing Final
Plumbing Top Out
J�
Equipment Enclosure
Shower Pans
®�G S
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
`
COMMENTS:,
- -
Final
Utility Notice (Gas)�9�
ELECTRICAL APPROVALS
'' .4
Temp. Power Pole,
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
_
Main Service
..
Sub Panels
H
Exterior Receptacles
`�
G. F.I.
Smoke Detectors
Temp. Use of Power
Final——O
y
Utility Notice (Perm)
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211
I Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
"`❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
OTHEIP�
JOB LOCATION
631 L) _ i Cc>l FiS \
REPORT SEOUENCE NO.
Tv,QEOF SjgUCTURE
PERMIT NO.
DATE
DAY OF WEEK
MAT V4AL DESCRIPTION
NiMPSOCN � 52-79
ARCHITECT
INSPECTOI
NRS. CHARGED
104
ENGIN ER A 1
�, V'
ASSISTANTS
MRS. CHARGED
INSPEC ION GENERAL SUB T
DATE_._ _CONTRACTOR_CF=%-I\.6--,-,. _. .. .CONTRACTOq._-.._F(� •_.-
N,
it
i 0 � !( Wl ^t 4TV
-IS C04A-1 Oc C / V o
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A . f4'• OrnQr • t�
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COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY'
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. 1 HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS.. AND APPLICABLE SECTIONS OF THE
I
GOVERNING BUILDING LAWS."
J'
N
1 ,
SIG TUBE OF R ISTEREO INSPECTOR
1 crRo :sZ J-717-g�
+Tt OF REPORT REGISTER NUMRFR -
rel
Certificate of'0Ccu anqy.
� I•+f00sPOUTID � l .. V 'r j .. y
OF .� Buildin fs&;Safety Department K
This Certificate is issued p'ursuantao�the.`requirements:-of Sectiori-,-109:oftthe California Building,, r
`the:'-
,
. Code, certifying that,-' at`� the,,-'-time of issuance, this structure.Y,was , in4 compliance,- with .
provisions' of the Building J'Costa and .the carious•_ ordiranceYs_ of the City,,regulating building+
7 "construction andel/or use.
n
lLDING DRE S' 49=631 VIA CONQUISTADOR
,.,
- ,B
� ;�. . -. .. � , .. .- _ . _ ..
�' n . � + x'11.. 'N' n o ♦
_ . _
1 i
Use cia�sificatiori: SFfD' L r- - �' > • : �uiidmg Permit No:; 0301-061 .
' Occupancy Group: A-3 .N `Type'of Construction. V'N ,-` 'Land Use-Zone: `R-L. I
-
. Owner..cif Building: 7D.DESERT DEVELOPMENT ' . ,�Address:9-295 iRANCHO LA QUINTA`DR'
City*, LA UINTA CA 92253'—":-' .r
By: G.SHQWALTEO,
Date: 01/09/04
Buil Ing Official .. _ ,
- ' POST IN A CONSPICUOUS PLACE a`