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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
Professionals Code, and my License is in full force and effect,
License # Lic. Class Exp. Date
Date Signature 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.
(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.
Date: 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 subjeci 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 representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
:,+: A W..Wf IIMEk3'iW, A35(K 3An. 0.M
1) 10 . MA[? PACiNU- cMNIOW. C.11)lXd'.E AU1'+
PO DOX 064
1452 MY-1-IN11 AYL lrf3 g
I.AQW i'A1 CA 92253
$0LANA"X!H fuA 92075
0158)792.1 w (TBIA
USE OF PERMIT
I,0C''-AI, ":MqC K IN I*fiia ATION
;:f 1 tr'''c'tt
c'• t r
.4,636.!r -6A &_54-612 fFAI{. 'YREF, • AdlLJ' IN�
0 VR )-'. 111141 AV
V.A IAJATION xiltui+ .Op L
ir�.�'INiA'!�I) [_'[,ify7' C: ' , . '' : '. t •- : + t ° i^
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I1Vk&4A'V V.iM WP41AARY
CON}OTRUCkWN PV1, 101.000.416,000 120.00
5T IR[7hICj MOTION P'H? 1tE'.S10 M-000-24 U.Ne
jDpyR7.�.p ■1fA^,
$209.0? r
CITY OF LA OUINTA
FINANCE DEPT
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs
I_
Forms & Footings
Slab Grade
/
Steel
Roof Deck
O.K. to Wrap�41�G(
Framing
�ir/rl /ni
Insulation
Fireplace P.L.
1
Fireplace T.O.
I
Party Wall Insulation
j
Party Wall Firewall
Exterior Lath
f
C 11Y_ I
Drywall - Int. ath _
4zL�ei
fr01
�� •• — -
Final
911.*/�L
SLOCKWAL'. ,11-1 '' Ov.
1_3
Set Backs
Footings
Bond 13eaIn -
Final_ I I —
PLUrvIBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
F Sewer Lateral f _
Sewer Connection
Gas Piping
Gas Test I
Final I 1
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)
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A U. j
Compressor
Vents _
Gi ills
Fans & Controls
Condensate Lines I
Final
Steel
Electric Fiend
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
Encapsulation
Final
COMMENTS:
POOLS -SPAS
} w
tsl.i a
DAVE STEAVENS
Inspection Services
PROJECT C -, t1 � s '� r-r>g 5 E (R _ PROJECT #
ADDRESS A 5 (_ i 5—rc D
BLDG. PERMIT #
ENGINEER,k)L., ,—N,.] J O � � ►.] L
INSPECTION TYPE
Page J of o2
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CLIENT �� fl WE 5 r H o r4
DATE SLA 0 E
ARCHITECT GL -8A A qc. 4 re cru R—C
CONTRACTOR -le,L m,4 K -,V4C r F/ C
INSPECTION REPORT
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. _ CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. — C] INSPECTOR NAME R v tz. ►�f cfGr U
DATE 3u,eJt 2L001 INSPECTORSIGNATU
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M
DAVE STEAVENS Page -l— of
Inspection Services
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PROJECT 3?L6 kZZ S i j?Nflsr 1h PROJECT # d Jo l - 3
ADDRESS - A 5 L i s -r if D
BLDG. PERMIT #
ENGINEER'� t,i.,i S P a -:=,)c-
INSPECTION
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INSPECTION TYPE
CLIENT A OE-; �/pA
DATE jJ E .Za U I
ARCHITECT +yo[.�3
CONTRACTORS L MS {z '�A c, r-+ c
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
pubstantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
,-the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. - S� D INSPECTOR NAME
(Print C rot's
DATE i t rJ E �y 0 1 INSPECTOR SIGNATURE � - �,
DAVE STEAVENS
Inspection Services
PROJECT S AU P -s , R5L f A PROJECT #
ADDRESSL-t-s-rCZ
BLDG. PERMIT #
ENGINEER �,.� �\ 5 A J a t i C.
INSPECTION TYPE
Page I a I
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CLIENT(R
DATE j -'rc.x-O t a cid t
ARCHITECT 9- Tu AC
CONTRACTOR b6(- M A K _ ?Jkg Ft C -
INSPECTION REPORT
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,CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
substantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
the locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. INSPECTOR NAME k _ 0E, ,E AJCEJ-1S _
f95rly�
DATE V O INSPECTORSIGNATUZ�