0209-019 (BLDG)LICENSED CONTRACTOR DECLARATION r:
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
4�y'3 d Ai. fl,rr "`
Dat;Signature of Contractorr`1-0/
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.
(4 1 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 STATF FUND Policy No. 044.91L XIT 091012
(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 workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
s,Datel!'a.-1i 6A531icant �+'�. .: �iy / �i'f, •:.,f�.�/ t .
�.�
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 applicator 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 Js
correct. I agree to comply with all City, and State laws relating to the buildings t
construction, and hereby authorize representatives of this City to enter upon
the above -mentioned propertyfor, inspection purposes. ,.
Signature (Owner/Agent) %..� --.�' � ��"-.��� Date Xel • � ".�
;;7 _ BUILDING PERMIT PERM'02("�19
DATE I r-+ VALUATION LOT TRACT
JOB SITE
ADDRESS 4 .9,
APN.
OWNER '.
CONTRACTOR/DESIGNER/EN INEER
KSL, FSM; 'i RVSO RITS t`i3'er°
!%1L.m) VALLEY C01v a 1:.Ti.UM:tCYX COA : llc
LA QJ:t14TA CA. 92253
BLOOMNia w CA 92316
(+909)8i5.2112 C.i a-9 6507
j
USE OF PERMIT
NFRAL Bi,"Ii..01140
CCnizrwref81 . 65 Et *1 hetIdiQY➢C13alnY & 1�4QYLtYt 191i.{°,l3tY>?Y).
'lower, YT-2 0-H
CONTRACT AMOUNT KOKO 113
CONSTRUCTION FER 101-000-418-007 ?._ � $4"_"
PLA24 CHECK FFK 101-000-439••319 330•f1Q
� r
LeL. ✓ t R1t,.A L NCB 01-000-420.000 $30, 00
3TR(.5'NC1 MOTION 1+S'F,',f - COMM 100-000-2 1-000 ' $12.60
GRADIWO. RrE 101,.000-423y000 W.Do
ART ie4 POD1,1C VL�i'kCZS - GfaX0 2...r 0-000-44115-�000 ��lls.Qti
�a
PI". i.RTiLbZ
L10 121 PRE -PAID n09
SEP 1.0 2002
i-- •.
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final I I
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Gas Piaino
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor s -
Vents Y'
Grills
Fans & Controls
Condensate Lines
Final
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
POOLS - SPAS
COMMENTS:
SC i� is .✓J/�t-Ti o i✓ r 7'L
` 3/./
OM (444 %% pZv ? / s
I Final
( 9 ITY OF LA QUINTA
(31 DING & SAFETY DEPARTMENT
OF 777-7012
a 1 SPECTION REQUEST LINE
LU 777-7153<---�
Owner WE R1 RESORIS INC
Cont r AND ALLEY CONSTRUCTION CO, INC
Permit Number 209-019
POST ON JOB IN CONSPICUOUS PLACE
INSPECTOR MUST SIGN ALL APPLICABLE SPACES
49-499 EISENFfO'WER DRIVE
JOB ADDRESS
Commercial - 65 foot height Monopalm
Telecommunication Tower. U-2 Occ., Type 11-N
TYPE OF INSPECTION
DATE
INSP.
TEMPORARY POWER
SETBACKS
U/G PLUMBING / WASTE
U/G ELECTRICAL / GROUNDING
FOOTINGS / STEEL
litG 2
CONCRETE SLAB
DO NOT POUR CONCRETE UNTIL ABOVE SIGNED
COVER NO WORK UNTIL ABOVE SIGNED
INTERIOR GYP. BD. DRYWALL
EXTERIOR LATH
GAS TEST
SEPTIC ABANDONMENT
SEWER CONNECTION
SEPTIC / GREASE INTERCEPTOR
MASONRY INSPECTIONS
FOOTINGS / STEEL
BOND BEAM
POOL / SPA / WATER FEATURE INSPECTIONS
PRE-GUNITE / SETBACKS
U/G PLUMBING
U/G GAS
U/G ELECTRICAL
PRE -PLASTER ALARMS / BARRIERS
FINAL INSPECTIONS
TEMP. USE OF PERMANENT POWER
ELECTRICAL
'MBING
_ .;HANICAL
PUBLIC WORKS DEPARTMENT
COMMUNITY DEVELOPMENT DEPT.
FINAL / JOB COMPLETED
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
TURN ON UTILITIES OR OCCUPY BUILDING