0106-193 (SPIN)LIIi CIVJCN VVIV 1 f7MV I Vll VGVLMnmI IVIV
I herem under. penalty of perjury that I am licensed under provisions of
voapt
ommencing with Section 7000) of Division 3 of the Business and
Profess) als Code, and my License is in full force and effect.
License # Lic. Class ' Exp. Date
Date (.z Signature of Contractor
r OWNER -BUILDER DECLARATONI' ? 1
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the followirg 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.
(--A, 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.
(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 3700 of the Labor
Code, I shall forthwith 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 subjeci 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 cf 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.
1 Signature (Owner/Agent) 1 f••• Date)
BUILDING PERMIT- It"M rr
DATE VALUATION LOT f;�I6�1� �I'^�.�i TRACT
,.;w
JOB SITE
APN
ADDRESS
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.�5.'4 fi:r.f'�,11?110.1 i1.9
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OWNER
CONTRACTOR/DESIGNER/EN INEER
)ty Y�7, N 7 •�. p, �'p y�: 1A
1 iT p 1 ' %j '�' Ta` •° "',[.� },.I (S �'� p� .o .. t Ory
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O G:}l,AN.d�t.'�t1t;,'�c" :i. CA `420.1
("i:�>^)1K�x•'i:iiDsA. 5823
USE OF PERMIT
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RECEIPT
DATE i
BY
DATE FINALED
INSPECTOR
I
INSPtCTION RECORD
OPERATION � r�DATE INSPECT
�^PERATION DATE. INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
met Backs '
Underground Ducts`
forms & Footings ry ^�
Ducts
i
Slab Grade
--
-"
Return Air.
�� S
Steel
Root Deck
—
Combustion Air
Exhaust Fans—
�FAAU.
- -- -- -
OX to Wrap _
Framing __i _
Insulation _ -��
Fireplace P.L.,
Compreasa
Vents
Grills
I
-
- -
T -_
Fireplace T:O. y
Fans & Controls
--
PWall Insulation -- — j -------------
-~arty
Party Wail Firew-all Y ! [
Exterior Lath 7
Condensate Litres
F�
6rywwalt - Int. LathFinal
Final
POOLS - SPAS
BLOCKWALLAPPROVALS
Set Baks_ ~~ _^.�,
. i
Foo
Steel
EkdreBond
T
Bu_ndeeam �
Dalin
Approval toCover'—
Equipment Location
Underground Electric�_M_
Underground Pib;. Test
0 -PLUMBING APPROVALS
_Gas Piping
las Test
_ _ _
Waste lines..`.
� Electric Final
Heater Final
Water Piping i
Plurnbirg Top Out _ .. .. �_
P'Nmb din irai
Fguipatent Enc!osure-
O°;{. for Finish Plaster
_
_ -- I —."•- _
_
Shower Pans
-
Sewer Latera's
Sevier C onnertic') L
Gas Piping
-
PoolCover
t Encapsulation
y
Gay Test
Appliances —_ ................. ......... _
_
Final
W
COMMENTS:
l
Final
✓�(J/!/I //
_ _ .._____._...
Utility Notice (Gas)
ELECTRICAL APPROVALS
I
U�� • ���
��
Temp. Power Pole
'
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
coke Detectors
1,
Use Power
of
Final
Utility Notice (Perm)
Page — of .
.,--'DAVE - STEAVENS
Inspection Services
PROJECT CaA ' t+JZ5; I
ADDRESS 'S44 - 913 SRI, S S- iso °k - 0 21
BLDG. PERMIT #
ENGINEER_%A,,,i l
• INSPECTION TYPE
PROJECT #/ - O 4
CLIENT � (.A LojesT N u A
DATE a.oro I
ARCHITECT C=pI`a a r4�CM I Eco u+2E
CONTRACTOR
INSPECTION REPORT:
Vb6+ -r o a 14 - 27-SA,iz L_ c-; r
49 L4E re
5 S o�g d- SAF -9q �LA 1 10
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f /, T' CoM
A
CERTIFICATION OF COMPLIANCE: To the best of our knowledge, all of the reported work, unless otherwise noted,
1 i 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 3 Sq 3 IeA - :5 CINSPECTOR NAME ��4 Jt 61%7A C/ 4C -J,:;
%
in Cleary)
i DATES �1'� aU� I INSPECTOR SIGNATURI���