0002-127 (SFD)Z_
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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
Profetsionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
0,' IJ 11'011
Date " 0Signature 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.
( ) 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.
nor w� • r=: rr. cry ",
e4 F.1.p i�i°l^4ia0 !+}'`J oeyrtrl 9,AU
(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 SR as to become subject to the
workers' compensation laws of Calif orniaand agree thatAf-f•;'should become
subject to�fie vlorkers' compensatiopeprovisions of Seddon 1700 of the Labor
Code, I s � all forthwith comply with those provisions.
Date:��'s� 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, 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 authorize repprresel;Itatives of this City to enter upon
the above-mentioned property for inspection urposes.
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Signature (Owner/Agent) �`t� f� / Date
C/
BUILDING PERMIT PERMIIIooll_ul
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DATE VALUATION %Z7i�o�� tRvb LOT1� TRACT {'9JOB
SITE
ADDRESS +9-430 VISTAL (..jai. RD
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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9.2)5 KANCH0 LA i;+UiN'Z A DR.
irAt,)d INTA 'A 92253
12�AQWINTA (A
t'11601 71-1,9.af r�r to 2i
USE OF PERMIT
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RECEIPT
DATE
By
DATE FINALED
INSPECTOR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
p— pa
Return Air
Steel
Combustion Air
Roof Deck
— /0—&0
Exhaust Fans
O.K to Wrap
'
��2
F.A.U.
Framing
Compressor
or
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
POOL -OAS
BLOCKWA
A PROVALS
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
zo — f
Gas Test
Appliances
Final
COMMENTS:
SZ3—� ems 0A-- 14W
Final
�8
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
AlfZ
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
M 41
REGISTERED
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 9221.1
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
❑
❑ OTHER
JOB LOCATION-Li-3D
A q �; CIO
1V� -
QL �`� �
REPORT SEQUENCE N0.
TYPE OF STRUCTURE
Sfp VFA
�NCarV11asE
PERMIT NO.
LATE
5 i5 bO
DAY OF WEEK
MATERIAL DESCRIPTION
inn SAN 5LaXq
4945
ARC HITECTIYSPE
.els=MLEK- e.2Ai3E
TOR
'R,-D,.
HRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION
..DATE..
GENERAL
,CONTRACTOR
SUB ...� t
CONTRACTOR
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COPY SENTTO CLIENT ❑
CONTINUED ONNEXTPAGE ❑
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
"e NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS. AND APPLICABLE SECTIONS OF THE
f.nvFRNINf. RI III mmn I AW[
1141,
5 -hS NATURE OF REGISTERE NSPECTOR
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