0301-360 (RER)I hereby affirm under penalty of perjury that I am licensed under provisions of
i- Chapter 9. (commencing with Section 7000) of Division 3 of the Business and
N W Profe§9lonals Code, and my License Is in full force and effect.
' License # uc. Class Exp. Date
CY W 753152 B Fuc 03M1/2L
ZO Date Signature of Contractor
rz
J U OWNER -BUILDER DECLARATION
W ~ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
I
150 License Law for the following reason:
Z ( ) 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).
1. as owner of the property, am exclusively contracting with licensed
dontractors to construct the project (Sec. 7044, Business & Professionals
1 y Code).' /
� �y, I am exe �t der Section B&RC. k this r son
Date Signature of Own ,
d Q WORKER'S COMPENSATION DECLARATION
ZI hereby affirm under penalty of perjury one of the following declarations:
1..; p () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL- compensation, as provided for by Section 3700 of the Labor Code, for the
`O J Q performance of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Sj Section 3700 of the Labor Code, for the performance of the work for which this
11iin permit is Issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATE P' D Policy No. 04bf�1UN1T0009415
.
f,, g (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
r ter` workers' compensation laws of California and agree that If I hould become
t - subject to th wo kers' compensation pr Islons ol,�ectl 00 of the Labor
3 `,Code, I seta) t4comply with those rovlslo a.
Date: L �APPllcant ... •'.
Warning: Failure to secure Workers' Compensation coverage Is unlawf nd
i 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 3708
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
r 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, Indemnity
& hold harmless the City of La Quints, Its officers, agents and employees.
2. Any permit Issued as a result of this application becomes null and void It
work is not commenced within 180 days from date of Issuance of such
lIU1 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
j • Y correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby auth rize represents Iv of this City to enter upon
the above-mentioned property r inspe vOn r oses.
Signature (Owner/Ageht) < "` Date
BUILDING PERMIT
-_
DATE / f VALUATIONLOT TRACTJOB
SITE
ADDRESS KMG. $2 LXOK S - INV$1MBS
APN
t
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PGA WEST diEMENTIAL ASSN
DEL 14LAR PACIM GENUAL CONTRACTO
P.O, AOX.1060
2533 SOU111 COM'1' ilYC3I3WAY STS 250
LA QUWA CA 92233
0Ai2I' DV ElY 3M 3EA CA 92007 .
(160)6:5.1010 C'.BLfl! 5823
USE OF PERMIT
C;}ENnAL K1I'I.:L' ING
OLDO. 22: 54.7'70, 54.7K 94.762, 54,75X. VOLUNTARY
STRUCTURAL MODIFICATIONS
VALUATION 20,OUtr.1?f! us
ESTIMATED COST OF CONI rRUC'TION
'20,000.00
PERMIT r17".R 911MMARY
CONSTRUCIfIONFitlit 101-000••418-000 f2tt'd,GO
5TRONO a1 OTION tt'FE.- RIM110 101-000-W-000 114.00
FEB 0 3 2003)
CITY OF LA QUINTA `
FINANCE DEPT.
SUB -� I'CX AT,. t�C7N9'OMC 014 ,,AND P AN C'H�' X ``
$209.00
.� TMS PkR-PA DPIKEJ
$0.100
'IMAL PIMM1YFE EN 1)VE NOW
.00
RECEIPT
DATE i' ;
/
BY
DATE F�LE
V-3
INSP T R
11
• /.
lot
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Duds
Forms & Footings
Duds
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. 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 pR
POOLS - SPAS
BLOCKWALL APPROVA S
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:
I�IXIO3
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)
DAVE STEAVENS
Inspection Services
PROJECT ry r% PROJECT #
ADDRESS :5q ' T9,16, 2, 7 71 0
BLDG. PERMIT #
ENGINEERv ►� Jvr :i, k .
INSPECTION TYPE
r
,s
Page
(5 ,
c of r
CLIENT ?6,A LJCS7 (4aA
DATE / q MA -1- 2->v3
ARCHITECT (;Q( -.6A
CONTRACTOR,h,. (- 1"A i2 h'� e r i•4 / r
INSPECTION REPORT
t-jc. y AJ s4 t c. , ,,.J G -- Com.+, J e. e t k'
. t i ia,f-S W ,S-�" 1"�;2K�r �aC�AL 121rTe,Jz A,-) / C `✓dA ..,i�e.r.'7G:
r ,
,..��""1 ►a � tr'� - � � 5 - � " �f�!��lr � " 7�1�17 -{ �,1ja c. r.,.. � l �.i G.�' ,� �7u! � %' +� ,cl
rl
1 c.S A,%,1
L T`
15•'i tBLIC,� U!')�L`/ X/t{rc
""4, , 11-4) P1 i tlO r c, A✓ L. i_ V •r•• c. t; i� c<.
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 ,
y he locations of the work inspected only and does not constitute engineering opinion or project control.�,�`;
CERT. NO. �✓`.> 'i `�O INSPECTORNAME,J �� {i d'L)
` � � (Rrint,Clearl
DATE I Ll f� r ✓ INSPECTOR SIGNATURE,
7
DAVE STEAVENS
Inspection Services
PROJECT
ADDRF,SS:5-,/- 17/,,) ?(,6 77e>
BLDG. PERMIT #
ENGINEER It: :VOr-
INSPECTION TYPE
Page I of I
PROJECT # 1;? 00 3 -0 `i
CLIENT ?6A tAJESTI f4oA
DATE 13 m A',1 � uo S
ARCHITECT t�,o(,tgA Q V-4
CONTRACTOIRLDCL, MAZ PACIFIC -
INSPECTION REPORT
Coll,
A
-7
, %- S -- -5'l s - t -` j. .2 x s Sr- otAI, 4)�
�3L ac xe,,J4�Li S, I- - '710-5
S C'i
:Pt a
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
ed only and does not constitute engineering opinion or project control.
locations the work inspect'
CERT. NO. INSPECTOR NAME A 5
(Print Clearly)
DATE INSPECTOR'SIGNATUR;I'