0301-369 (RER)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 t1 Lic. Class Exp. Date
733)'52 B iiic 3/31 /0:
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).
VY I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & P4sionals
Code). '
() ,I a2eletpZ under Section , B&P.C. for this r son
46ate Signature of Owne( _
WORKER'S COMPENSATION DECLA ATION
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
on 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 STATS KYND Policy No. 041001UAIT0009415
/ BUILDING PERMIT.
DATE j! VALUATION ryyti LOT b TRACTJOB ,
ADDRESS
3XLCaANIiS - �hi�� APN
OWNER
PGA Wim' MWID"NrIAL A:Y13IN
P,O. BOAC I M
I.A (7UilefA GA. 92253
USE OF PERMIT
Clk.�i1731.M1 I', f )[IL33IN C3
CONTRACTOR/
DEL MAR 1PACMC: GHNEXAL CONIVAC
2533 UOUTH COAMI3IWWAY SM 250
C".D11eF BY 7.1' , :SFA 'CA 92001
(70Y)635-1010 CBIr1f 5823
BLD0. 31: 54-476,34459,54-440,544.22. VOLUNTARY
I;TRUCTURAL MODIVICATICYNS
VALUATION
4000,00 I.,a
INAIM) (°OS"L' OF K:f.?:l.V.111ZIJtTION
(This section need not be completed if the permit valuation is for $100.00 or less). C"•ONSTR.UC'11014 FIX1 103 -000-418-000 $20.00
O I certify that in the performance of the work for which this permit is issued, STRONO MOTK N FEB - RESIV 1x.11.000-241-000
1 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 he orkers' compensation provisions o Sectio " 00 of the Labor
Code, ass Int hwith comply with those rovisio
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.
Fq
,
FEB 0 3 1UU3;.
CITY OF LA QUINTA
FINANCE DEPT.
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 upoh whose behalf this application is made &each person at 5311.9-'j'(79.`AL COMM.ii -11014 AM 111J41 chri IC
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 jr I'&M U I*ATD M.
& 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 'B.TCY.rAI, FERM11' FEES I.1t7EN()W
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 represen ves of this. City to enter upon _
the,above-mentioned property for nsp tlo rposes. RECEIPT DATE eY
k
3 gnature (Owner/Agent t " Date
DATE
2010M.W
$209.00
$0.Ocl
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Duds
Forms & Footings
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVAL
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:
^
`
r
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)
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INSPECTION. TYPE
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherw
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ubstantially complies with approved plans, specifications and applicable sections of the building codes. T1
locations of the work inspected only and does not constitute engineering opinion or project control
CERT. NO. '59 INSPECTOR NAME tj
DATE .3 t ,(jt' . OC)3 INSPECTOR SIGNATU a. C &-C-C.1 s /Ud<
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherw
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ubstantially complies with approved plans, specifications and applicable sections of the building codes. T1
locations of the work inspected only and does not constitute engineering opinion or project control
CERT. NO. '59 INSPECTOR NAME tj
DATE .3 t ,(jt' . OC)3 INSPECTOR SIGNATU a. C &-C-C.1 s /Ud<
DAVE STEAVENS
Inspection S.ervices,
PROJECT A ST• rA-L
ADDRESS':S'4/-4fAJ,'Y'40 &11(0
Page of
PROJECT #
CLIENT NA uli_ s -r 14co
DATE fA fl 2 00
BLDG. PERMIT # ARCHITECT
ENGINEER L--4NJ SAJUsc ��",n1c CONTRACTOR-ZE:L /AtVI
INSPECTION TYPE
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted
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bstantially complies with approved plans, specifications and applicable sections of the building codes. isrei report covers``
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locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. 09119 50 INSPECTOR NAME
DATE CV /VIA a 4WI-5 INSPECTOR SIGNATURE
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted
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bstantially complies with approved plans, specifications and applicable sections of the building codes. isrei report covers``
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locations of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. 09119 50 INSPECTOR NAME
DATE CV /VIA a 4WI-5 INSPECTOR SIGNATURE