0002-128 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chap•,r 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
I.irense # Lic. Class. Exp.. Date
cr�37-"'�%�,`i
Date d -7Signature of Contractor .p
OWNER -BUILDER DECLARATION J/
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.
( ) 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 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 ssolas tot become subject to the
workers' compensation laws of California,yand agree that if I should become
subject to'the workers' compensation provisions of Section 37� ffthQ Labor
Code, I shall forthwith comply with those provisions i{/
Date: o�' h 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 purposes.
Signature (Owner/Agen_t) ! Da eL_ 1-N
- 16 BUILDING PERMIT PERMIT#
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DATE VALUATION Q4(0,117.10 LOT F) TRACTJOB
SITE
ADDRESS 49-41f, V.�r�TA;Cfbi@ee.I.CO
APN 649-104 -60
OWNER
CONTRACTOR/DESIGNER/ENGINEER
LA t, UIN'I°A CA V2253
LA (,AJIN !'A C' --A 92) 53
t 70�1771-1911 (1111,10 N46
USE OF PERMIT
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RECEIPT
DATE
BY ��-;, ,,.+''
DATE FINALED
INSPECTOR
INSPECTION RECORD
4 OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECT R
`k 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��
Framing
�
F.A.U.
Compressor
Insulation
-0c) "C
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath47
i
Final
Final .`-
BLOCKWALL A VALS
POOL -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
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 XPPROVALS
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)
. g5
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave..
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
O POST TENSIONED CONCRETE O ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
O
O OTHER
JOB LOCATION-
48,� 1 ®
8 S 1 (1a' � a����
ii PORT SEQUENCE N0.
TYPE OF STR%TURE
SfD 1'Ritt°X,
i F
NaSE
PERMIT NO.
CATE
5
DAY OF WEEK
MATERIAL DESCRIPTION
inn 5 � N
d k 3t-gt9 4945
ARCHITECT
INSPECTOR
MRS. CHARGED
ENGINEER
ASSISTANTS
MRS. CHARGED
INSPECTION
-DATE
GENERAL
CONTRACTOR.
SUB
r CONTRACTOR '
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COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE O .
PAGE OF
S' CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
T(NOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTEJ). I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS, AND APPLICABLE SECTIONS OF THE
f.nVFRNINr.. RI III nINF: I AWC -
ZA)
i�
S NATURE OF REGISTERE NSPECTOR
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