0201-085 (BLDG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions 6f
Chapter 9 (commencing with Section 7000) of Division 3 of the Business a/d
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
7 + 152 i'• ,' , 3/31/63
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.
STATE FUND 046011.4111'0009415
(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 370Q of the Labor
Code, I shgll foo6w,itth comply with those provisions.!
Date: ' ' Applicant-
Warning:
pplicant_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 applicaton agregs to, & shall, Indemnify
& hold harmless the City of La Ouinta, 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 160 days from date of Issuance of such
peffnit, 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 is City to enter upon
the above-mentioned property for Inspection. purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
ATE / f' VALUATION LOT (Y201•085 TRACT
J $2010w=
JOB SITE
ADDRESS
APN
1+=114TONK
_
OWNER
CONTRACTOR / DESIGNER / ENGINEER
110YA WFM id:ki H)EN7W, ASSOCTAIT014
IMU, MAR PACTA'3C OFtNERAL CONTRACTOR
PO DO X, 1060
2533 801MI CO,P,;1.1' FUGHWA.Y nTTF. 250
LA Q1,111'TrA CA
CARDIR BY IU M;A CA 92007
(7B(3;i:5Er1-950(1 �'iT�! St323
USE OF PERMIT
13UILDIN(] 28. 54.961, 54 -9R3,34 -405,54-0V • 'VOLUNTARY
STR.UC'I`URAL MI)DWIC.ATION3
WAL UATK N 20.000.00 LS
MAIA.17D COR' 01P COINFITt1.►C'I ON
20,000.00
PE'T2A+C1',C.YI'1 .:gT 134ARY
CONIOTRUCTION ALT 101.000-415.000 $207,00
STRI)NO MOTION F>~:E • R.E51C; . 101-000.241 -O(.t0
F J
JAAJ LLCr;2
SLFFE•TO AL CONS `RT.FM- ow AND mi AN CHEc1K
$209.(K)
• 1XV A Rtx-PAIl}VES
$0100
TOTAL PM41T FUSS DM NOW
$2t19.(N•1
RECEIPT
DATE
BY
DATE FI LED
INSPE R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Foo Ings
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 8 Controls
Party Wall Insulation
Condensate Lines
PaV Wall Firewall
Exterior lath
Drywall - Int. Lath
Final
Final z zz
BLOCKWALL APPROVA S
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Final
UU14 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)
COMMENTS:
DAVE STEAVENS
Inspection Services
PROJECT -A W k -sT -
ADDRESS S' Y
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BLDG. PERMIT #
ENGINEERS�ti- _ 34 i�.J -C. �w c
INSPECTION TYPE
Page of
PROJECT # - u f
CLIENT j4n14 N u 4
DATE
ARCHITECT ,/- O L 14 4 4 C,14
CONTRACTOR c.- L- 0' 141Z
INSPECTION REPORT
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CERTIFICATION OF COMPLIANCE. To the hest of our knowledge, all of the resorted work, unless otherwise noted,
substantially 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. d `�] " INSPECTOR NAME J C- SAC-/-1 acf-. 5
Cleary)
DATE 17 u L INSPECTOR SIGNATUFOC*' ��
DAVE STEAVENS
Page of. I
Inspection Services
K
PROJECT U r\ 1.1)47 5 i � � C��. PROJECT #
ADDRESS t 54, -/t33 4Ca, I CLIENT
r i•d w a Tu J tic f„ � i �;J ,jam DATE L Y 3 c� 'Z
BLDG. PERMIT # ARCHITECT
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ENGINEER ,.V cx a ,J 'rd J,'�) e- I til C. CONTRACTOR
INSPECTION TYPE
INSPECTION REPORT
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 # ons of the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. r) u '4 U INSPECTOR NAME
[Print Clearly]
DATE ::��C '/ i INSPECTOR SIGNATURE