0208-118 (RR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
HChapter 9 (commencing with Section 7000) of Division 3 of the Business and
cv W Professionals Code, and my License is in full force and effect.
License
y#r�cC.p Lic. Classlyy Exp. Date
ryry
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Lill
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Z 1�_ Date 'T— Signature of Contractor /�./
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J U C) OWNER -BUILDER DECLARATION
Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
( ) 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
ul
O N Date Signature of Owner
0)d Q WORKER'S COMPENSATION DECLARATION
> Ir I hereby affirm under penalty of perjury one of the following declarations:
Lo FQ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W !:!= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
ED U'U(�) I have and will maintain workers' compensation insurance, as required by
O Section 3700 of the Labor Code, for the performance of the work for which this
I11 LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
?• Z Carrier STATS MD Policy No. fi 0?
0� �5-y
� V
(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, l shall,forthwith comply with those provi°ssionnss.
/Date: !Z �� ��' 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 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) 4, Date
BUILDING PERMIT PERMIT#
DATE VALUATION ��Jk�yf'.~l• LOT TRACT
JOB SITE
ADDRESS y'�
APN _ ..
OWNER
CONTRACTOR/DESIGNER/EN (NEER
Tdt" A. ZT W( -)P2 rIAL IIOME,viK IAT,,eS .
Z% VllEFi'IMN1JAMPTC ROOPWO
FO BQX 1.050
3462 IA CA -WAWA INAT
LA QTM- `rA CA 9225.3
PAL11A 8PPIWM8 C^ -.A, 92262
(760>416-5877 Cb1.4f 429:
USE OF PERMIT
E1.1.00.3% 55-327,5! -339,5i-351,55.363: #.L70? WrrH
POLYMM-1HAN9 FOAM cf ACTiYLIC Q«"'JATI140 KOOF►.KO RVISTM
VALVA° 10144 20018,00U
.MMy`a.g,L• D WE D✓Ff C00OTRU�N.ilos
a 20,4280111
IBRCVl7 FEES1 C l _o 1L1 418.000 n ��It�Q:
i
• Q! ir, n � ZUOZ
CITYOFLAQUINTA
FINANCE DEPT,
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i�3�°l�, G�Y7 JiEi'�"LGi7:ti1� I'l: d]' C,11� t -
1W33 YIRE4`ITAID FM
$0.00
TOTAL PERM FEES DU; H4% NV
MAKI
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RECEIPT
DATE
BY
DATE FIN LED
INSPE R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
iZ
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
V
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final Za�6
ELOCKWAI APPROVALS
Final
POOLS - SPAS
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
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)
COMMENTS:
.; ., �'` - - - • • - - •- - - - - - Page i of
DAVE STEAVENS
Inspection Services
�v
PROJECT k( -A Q C5 - 1, r ckz --s PROJECT # ryQ " D 9
ADDRESS uS-3L3.3�''i.339.3�1 CLIENTPOA
�a DATE o7 l
BLDG. PERNUT # ARCHITECT 6m.,1,A Ail: H
ENGINEER btxatJ SN Not -e f a C CONTRACTOR -b L..A PA
INSPECTION TYPE
INSPECTION REPORT
F
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CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
J;,
bstantially complies wilt approved plans, specifications and applicable sections of the building codes. This report covers
tbcatiainJ'(f the work inspected only and does not constitute engineering opinion or project control.
CERT. NO. � ��..� �L7 ” �G7 INSPECTOR NAME` J C. rG`-iCW L OS
DATE ,O 7 -:n. jC ;4x 2- INSPECTOR SIGNATURE �'�...aa•
I
Page of
DAVE STEAVENS
Inspeciion' Service.s
PROJECT C, St - L t: (., 4C i
ADDRESSES- No S 3 S'!, 'a X ,32 q
STT
T-1
BLDG. PERMIT #
ENGINEER 'D4.#-oJ SA&mC
INSPECTION TYPE
PROJECT # 07-00'a 014
CLIENT '�C-->A &A e TbT Hopt
DATE
ARCHITECT Gy Z*1 N04.
CONTRACTORb6L Ail 141L
INSPECTION REPORT
4,r,r I C- S144:Aci'&y•7 1r 3Ct 4. C
Wort
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CT %I Is* q (,JA L 4- A J4 A. 9JA"�ijje
-INO A I PA it 7-/ W A 594:d1z AA1410LLt Aea<k---
b dLY AIA Jc. L e. -f C—r
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,,;;," I
!
ubstantially conVfiesys
:,#h approved plans, specifications and applicable sections of the building codes. This'r pgrt covers
work Inspected only and does not constitute engineering opinion or project control.
CERT. NO. fJ
INSPECTOR NAME ZA
DATEC;P�R alool INSPECTOR SIGNATOR