0301-364 (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.
Licenser Lic. Class Exp. Date
_A 7331-4z BWC 3/31/03
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
tqbntractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am axe pt nder Section , B&P.C. llr this re `n
Date Signature of Owneir -_ f
ORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
() I have and will maintaina 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 0TATZ FOND Policy No. 04601 UMT0009415
(This section need not be completed H 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 3700rof the Labor
Cgde, I s all folthwith comply with th a provisions. / %
ate:jE Applicant ,'
Warnin : F lure to secure Workers' Compinsation 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 representativ9s of this City to enter upon
the above-mentioned property f r inspection pyfp/Oses.
tt � t 1
gnature (Owner/.,eht fI "� 'Date
rtnnu i x
.• BUILDING PERMIT _ aa,z,fx?AF
DATE VALUATION Iy� - LOT
JOB SITr=
ADDRESS MX0 a' 26I&MM - MVERNM
APN
OWNER
CONTRACTOR / DESIGNER / ENdIINEER
KJA WW R:F..SI' EITITAL ASSN
DFI, MAR W C IRC GENERAL CON RPLIM
P.O. BOX 1060
7533 30WH COAM IHUH.WAY ST1;S, 250
I.A QUINTA CA 92253
i ATeTxrR BY Tflk'8"XA CA 92007
(71.0}635.1010 C:PAR 58.3
USE OF PERMIT
CEL�NI;�.'t.AL T31331..1�INr4
54.652, 54,44X, '54.644. V G1,01SI'1'ARX
HLOCI.. a2p6�
ti5t•�65�6,t
STRUC"i RJRAl.6Y1�>DIFI:-A IONO
V.A.I.UALTRrYN ittti,d�Db 00)4;
KS1'kMATIM) C:OFf OWY t.07`'i8MtTC1.'X)N
.201[00.(0
PFR.WT F E' U:fl►4't1 UZY'
c'OM7'RUCTION 1+'PF 101.0000 1'x•(141!! $`1i�J,pll
w'1'ttC�NCf fvlC)'t'lCiti F'hE •.1LN9lL7 101-o(K)_241-000 �af.p0
FEB 0 3 2003
CITY OF LA QUINTA
FINANCE DEPT.
SUB -TOTAL AND PLAN MMIX
$209.00
LE30 PRE -PAY) MM
$0.00
TOTAL DUMC MIMS DUE 14OWa
t�tC01 M
RECEIPT
DATE
BY
DATE FI ALED
INSP T R
s: .Tell
a
INSPECTION RECORD
z OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
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
FA.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final 3
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam I
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Testy
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
COMME TS:
`
p
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)
V
_ DAVE - S'TEAVENS
f. Inspection Services
PROJECT 'PCNA. s -t' G�GEx1
ADDRESS S4' -(, 0, (oy 4, S�44 S6
• riv� r? �/G5S / t9G pz,4a �n
BLDG. PERMIT #
ENGINEER"Z).Ay;J "�:A Jo +C . .-r�►!c_
INSPECTION TYPE
Page of aZ.
1.
PROJECT # c90,03 -09
E
CLIENT?61'\ Ls,) ti. sT My A
DATE c;ol tsi 1a `'% d vc-� 3.
I
ARCHITECT Got -6)4 A i?C I4
CONTRACTOR Dom- Mr1 I AC tf= /C
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
,ubstantially complies with approved plans, specifications and applicable sections of the building codes. This report covers
he locations of the work inspected only and does not constitute engineering opinion or project control.
CERT NO.ya < 3 U INSPECTOR NAME z r"4 V C tJ
DATE-:�J I'q y s 1 C� INSPECTOR SIGNATUF�4 � - �C, • ,.._