0004-0158 (WALL)48950 Avenida Anselmo
l ,-1 LICENSED CONTRACTOR DECLARATION
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 # Lic. Class Exp. Date
7577.20 C29 01/31/2(
Date 'i 1, ` A Signature of Contractor k _ -J
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.
(G""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 Iw'TATI FUND Policy No. 154221$-00
(This section need not be completed if the permit valuation is for $100.00 or less).
J(,,) -(`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 3700 of the Labor
Code, I shall forthwith comply with,.those provisions.
Date: '/A ,/.; rt Applicant ? *: rrr... `, •
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) - Date
rw
BUILDING PERMIT PERMIT#
/
/VALU ATION LOT TRACT
/DATE/% J/ 1J?.L
JOB SITSAPN
ADDREss , AYFsITI,DtA ANSKLMO g
631-33170117
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CI3AA.I..E3 & CAROL RORMT
JAMES FEDOR MASONRY
54-508 T411MMUS
78.990 BAYBTMRYLANE
LA QUJA1TA CA 92253
IAA. QUINTA CA 92253
('760)772.3036 CFB.4 5713
USE OF PERMIT
0F.NIMALBi:InDD4G
4001.0.6'CI) CAItL?XN WALL ONLY.' -01XO STANDARD PER APPROVED
PLANS ONLY
6 FT. WALL 400,00 LF
4
ESTIMATKM C 015 OF C0fl9f.RT7C.r.D.OX
10.0WA*
CONSTRUCTION TSE 102-000.4.18,M0 $117.00
LJ
Lit
fLTB-TOTAI, CON:b 311-110MON• AND PT..kg CMi,CK
$117.00
IMS PRE-P.AM FZRS
$0,00
10TAL PMU-r FUS VUE .1` OW
$1J.7X*
IIIIIIIIVIIIIIIVIIIIIII 03
IE
RECEIPT
DATE
BY /
DR INALE01
INSPECTOR
E
IN RECORD
OPERATW4
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
OX to Wrap
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
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs _
Footings
Electric Bond
Main Drain
Bond Beam .7-_
Approval to Cover
=z yyd
Equipment Location
!fig cU rrt�
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP'kOVALS
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:
_......_.
i
REGISTERED INSPECTOR'S WEEKLY REPORT
JON TANDY
37630 Medjool Ave.
Palm Desert, CA 92211 �
Office (760) 772-7192 ..
Fax (760) 772-7193 .
Pager (760) 776-3338
TYPE OF
INSPECTION
PERFORMED
❑ REINFORCED CONCRETE ❑ STRUCT. STEEL ASSEMBLY
❑ POST TENSIONED CONCRETE ❑ ASPHALT
❑ REINFORCED MASONRY ❑ FIRE PROOFING
❑
❑ OTHER
JOB LO 1Rg Au" t OA t� S Ey ,,,� 10
+�v {
� U
REPORT SEOUENCE NO.
TYPE_QF STRUCTURE
�,'y," 'ND�.ee.N S'
PERMM'IT`NNO..�/
D 0 '04
DAV OF WEEK
MATERIA,K! TyON �
ARCHITECT
I!TCT RI ,
MRS. CHARGED
ENGINEER
ASSISTANTS
HRS. CHARGED
INSPECTION GENERAL SUB
n � �� � ► s CONTRACTOR U/ -jtv 1 es g 1�•-tc—
DATE CONTRACTOR f� ` O N
6 `` ' sm L tp-e 6-,,> LIS
St�12,v\
COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE ❑
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MY
KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE
NOTED. I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED
PLANS. SPECIFICATIONS, AND APPLICABLE SECTIONS OF THE
GOVERNING BUILDING LAWS.
/GNATU E OF REGISTERED INS OR
1 Q A `- LS
DA E Ok T
REGISTER UMBER