9810-038 (BLCK)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
j19i 5013 f ()
Date < Signature of Contractor f
w / vi
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.
iV I have and will maintain workers' compensation insurance, as required by
Sei%on 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.
(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' w?/kers' compensation provisions Section 3700 of the Labor
C6de, I sha I/ o hvyith comply with those grovisidns.
Date: `E% �' Applicant /J� �/ /��
Warnin : 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, indemnify
& 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 ButhSa�ize r presAtatives of this City to enter upon
th above-mentioned prope ��fornectio r purp s S.
Signature (Owner/Agent) Date( -
BUILDINGPERMIT
PERMITCONTROL#�I
DATE VALUATION $475.00 LOT
26+1 TRACT �® -3 / 2
j
JOB �ITEADDRESS 47-7I5VIA A10K1!' GO
APN �1 1 x.53
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�.w„f'ATNIA rD , . VCa. 1-n- 40 A 10'V
tC..+l' N ii%A ¢0, COMM" V�t l q �'A� li'
157'0.8.1LOO1�HOLLOW 1 fU %,, F,, SUITE 2013
1570 L�.RUC Xf1Oi.,t,�V'! DR1.1B, SLIM 208
Stl,NPct\ ANA CA 927015
SANTA tV%1*1. CA. !x705
(714YI51-9151. CBLV 4A?5
USE OF PERMIT
l:1jr`3�1�;l,-LA:i. ti1Jl'L�.311uCi
?fw1' 6',t- 15LF 4' GARl3FN BLOCK WALL
6 F7'. 1�IALL
3.00 LF
4 F►. WALL
Z5.00 LV
Pert fTlIi INTIM COST
014 �i✓J�Y� I RRUCT iN
`"x.!;1)
Fk 1
CONS'l7ZUGI'10N il�?S 1:01.-0€30-419-•000 $15.
a
S1.J13-'iY TA 1, CON STIR UC'1"ION ANC.) W, AN' CfIEQ;
81140
LESS PRS; -RAID PEES
$0.00
"i"t)TAL P)MAr9:)lT VEX 6)UC NO W'
s
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings /1j
Ell
Main Drain
Bond Beam 71,V
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final // Q
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
COMMENTS:
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
t
C
Final
Utility Notice (Perm)
eve;• 0CT-02-98 FRI 14:18 UAL -LEY BLOCK CO. INC. 7603426788 F.03.
619 322 5621 P., Eli,
GRr-0 'E,L.00K CO . I NC .
Service,
I n C
valuation ���`oRt IA90601•2299 Officials
►r �,,,,,, • wV-liTTIER) CAllf
• 5360 �-VOPIKMAN MILL ROAD t�rnational Conference of Building Off It
y cor oration of the in
i� subsidiary p Report
C DATION REPORT` SUPPi.
Cop}•r�. ae� EM�Ni
G� 1 S961CB0 Evah on Servtce,10c.
asonry
^Filing C ¢'4 ry: DES
wEOGt t.00K BLOC4 WALLS
51CuT1LE SiREF C
R1VEfiS;rJE, (.XUF09kIA 92509
c�15y0K; C'1., INC.
1155 ASTER AVENUE
SuNN' VALE, CALIFORNIA gb096
DRYS'Mffli BLOCK CORP.
Post OFp.C; 80X250
OJkLi. GAl,if RHIAS6632
VALEYFQS C IM BOXUX 100
lao, Cil.IF�RKIA 022OZ•1063
FtC-P 0L4:X A t3AICK, INC.
Z2 46 8 R0 AUW AY
ifhtoN t:fsOVE. CALIFORNIA 91945
quEs'IONE, INC.
ASTS VIAE1*0 AVENUE
LtiX.Lliid. CALIFOiiNIA93030
Wedgeiock Block Weds (Iss))ed November 1,19gS)•
Ado five I;stpes to report.
?add det;::is to mortared Mid joints W report.
Ep'don: A. General: lata Wedgek,Ck 8iockwall system conslst5
ct hollow rnasunry units with interiocking end webs placed in s
running-t--nnd pette(jl v:ith mortared bed loints,mortared or mortarless
hezd j041,15 and grouted cells with vertices MIAIOrceme:tt.
March 1,M_. _. •
nsts: The walls are comped of Grp,.:,
B. Materials: i. Masonry Umasonry O'
Type I o Type ll'hoUow concrete
STM C 90 95) and having a minin urn 8-sday
Staldard 21-4 (A 13.8 MPa). WedgelOCX units are
sive strength of 2.,000 psi ( hi h b 157le inchis (4L'
(143 mm) vllde by 7515 inchtrs (194 mm) 4 y
long. Specifically shaped Wedgelock units are avaslatste for c_ +
jambM1rm n other I with U8 C Stands. ard 214 may be usadortared dIn lieu of the .ry
cont. 9
lock unit describad in Section N A See Figufe 1, in master reps.
additional details.
g 2, 8 3, C,.0, No change..
E. tdentiticatlon: Each pallet of Wedge►ock concrete masonry
brarded or stenciled with the stlanufacturersa�d TJ1e
the manutal:turaes name and address, the Droduct tyP
evaluation report number (SR,5020).
III. Evldeoce Submitted: No change.
Findings
lV. Findings: That the Wedgelook StoC><Walis c011lply with ►,
Uniform Buildlny Codd', sun;ect to the loliowinq cordttlQns:
1. through 4. NO change.
5, Unless apectlicalry noted in ibis report supplement, +,;
evaluation Mort tem jlnb valid and ustcha0gttd.
This report eXpires concurrently with the mastor report e.s!'
March 1, loss.
rCBO, usujang tht 413dt upon ' ' ` un•
-- --~- other on i CI net SpeeiJreoW odcfressed nor 0.9 an tndonem+
Fvatu;:.non rtPorts of fCBO,r al tajion service, lnc, are rrtued,,r4 to provide In any
lhof an to Cissa maps o
Ir dosed EvalrW1ars rtporu ore not to bt eonttrwed as nprett+ t aeethetks or ony =rite
„yqn for use of the subjtet npatl. the 4 h..ant. rhe ICBG Eval"60n •v4rviet, rnt., uthnccai rrafJ �•..: ,ors
!b ICBO Era:aradon Srn',: •, _ .`:Jiry.
f 7hi� rt,. ort is bated upon indepe xicn: resu or arbor trchnlsol Qata submined by PP 7hb s no wo a tneludes, but isnot 1tr,ftv� r' '
i t:st rc u/u andlvr otntr daub but dun netpohsers lesrJoeiii:iei to mtrlte �eduepct cv�t d by�ho�Po Them it sc W4nan4 y
u�pur4 as to any "Finding" or other matter Iti the report oras ra Cny P