0310-093 (SFD)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
Profe:kionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
-.'Signature of ContractoE`�
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 R
() I am exempt. under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION. DECLARATION
t ( .g..
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintaina 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.
Z`) 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 & olic- no. are:
Cartier STATS FUN'. Policy No. �ti-5t3'�s33
(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 t� a y;0rkers' compensation provisions;of: Section 3700 of the Labor
Code Insh II forthwith complywith'those provlslon�s ;.:'
Date: ii ��f_" /? Applicants* 'a �:k, y1-'-1 . �� fi i, ..... .,
r 4_
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civilfines 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 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 auth1 1orize,rep(esentatives of this City to enter upon
the above- mentio:n1ed,,prope rty for inspection purposes.
� ner/ -• F+ 2x, .. ,+�tj .�! - ) c•• ,r,,, 1.x,.,,.1% 1 •` \�
�.Sign'ature (OwneS/Agent) --�� Date
PERMIT
;,BUILDING PERMIT.. PERMIT#
DATE VALUATION $234'�s.f67-40' LOT, jj TRACT 26983
JOB SITE 517-7E �iFC?uaeAG'`+'�MIR
APN
DDRESS
OWNER
CONTRACTOR / DESIGNER / EN INEER
F3YiiDMI.Elis n IIIIJ. Lcl*
:S'!'CORR
fl 1.1.
5 E, UM.M.,3 AV : O.M. 205
'MLAM33 CA 4'b3"93
RE9.7I ANDS. (°'A 923'93
. i
USE OF PERMIT
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PaO 14 ,0WA OR DTt EXYX APPRe�.M-K
CUSTOM COINWTRUCT1014 W80100 Of
SP
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X7,40
CJOWSYRUCTICYN FF, 10`A-000.4.161,000 61.115,54
PLYkV a 1'iWIK Fez $92V."
M.ii4pH,�IiCAL ITEM,:: 1.01 *000.427.00D :eM1i,00
E-1_1r;CTR1C.A:L FIMP 101_000-420-000 .. 92. 11,11
I7�KlYZE
u rRoua mO d ISI 4',L{ v o k , zr,,* 10" rioo `> : -ooD
O RAMIRG_FFIZ MR.
i?ywn-t PER I y"41 i_"T Fix,
8'ARWN I•'C;I3UV ^{:rAEN '7 _. RXSIC.270�C1( -445-000 W3,17, ,
$3,1 { e? -07
7T,3 2003
CITY O1 L.a culNrA
R tlig64ltil:
;DATE'
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
` BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings f../
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
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 _ 2 —D
Encapsulation
Gas Piping
Gas Test 1 Z:
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
Final
Utility Notice (Perm)
JON TANDY
78-194 Elenbrook Ct.
Palm Desert, CA 92211
Office (760) 772-7192
Fax (760) 772-7193
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY ❑ y I
❑ POST TENSIONED CONCRETE .O ASPHALT OTHER Ov-
❑ REINFORCED MASONRY ❑ FIR&PROOFING
JOB LOCATION /� os 1 i 1 A V ^ e aa?,, L A /1u_` h.�
<®v,_C/
/O�
REPORT SEOUENCE NO.
TYPE OF ST CTURE
PERMIj�il��� C)q3
DATEB �/u
ll
DAY OF WEEK
MATERIAL DESCRRIIPPTITIION XS c -
efj
ARCHITECT
IN,S�P CI+
HAS. CHARGED
by
ENGINEER -
ASSISTANTS
HRS. CHARGED
INSPECTION ENERAL p�e c ` SUB I i
DATE RACTOR Il i t G f� . CONTRACTOR ' . �/ �J
&S 6� 0 II ( 1 T14A-4.41
O�
t (f RL P,
L C-
COPY SENT TO CLIENT O
CONTINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV S TURE OF REGISTE IN PE
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE %
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED 3 " ;y; :.' p l ii
PLANS: SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS. ATE dF REPORT ' REGIS -ER NUMBER
., r