0312-242 (SFD)79800 Amalfi Dr
0312-242
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT
Professionals Code, and my License is in full force and effect.
' License# Lic. Class Exp. Date f ` ' el
752W 13MICr „ I R/31/0-1
1 -S2 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
Seiori 3700 of the Labor Code, for the performance of the work for which this
permit is •i9sued. My workers' compensation insurance carrier & policy no. are:
Carrier ' REPUDIC MDI?MNM Policy No. 13671602
(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 -.i —V 41 Applicant t /1 A.1 V4 /1
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, agehts 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.
4
Signature (Owner/Agent) A ate f — V-4
% ♦ J.. s v
PERMIT #
OU24A2
76 TRACT
JOB SITE
ADDRESS gA '!T f± APN"
'OWNER CONTRACTOR / DESIGNER / EN &NEER
1'aONIMM- CiSKHf3ME.8ft,I C. PONDEROSA1:>It3'•ilh °SM INC
400 S.:FARRELLDKNE,' &2W, B103 400 9, FAt2.Vn-J.,DR 2'UME,13103
PALM S"3C C-1 CA 92264 MM1 I3'iVRWGS CA 92226"
(103)187.710 C,HLA 2346
USE OF PERMIT
919OU9F1. AMILY 'T121c - I IIIII IIIIIIIII IIIII 54
3FO - L,0 i 76, P1JN 3.! X1., ,PERM1'1' DO -`.3 WOT INCL UDE BLOCK IE
WAi.IA P004 ti PA OR l?RiVGWA'1' APPROACH -
Tk3ACT CONSTRUCTION V5100 9F
si0RC'HfP.AT10
' 300.00 Si:
(M11AMICARP[i1LT.
01.00 S
ER.i'.lMATED CO,'',r Or, COMML7C.U? N 185,775.50
Y'l ' MCC 1i'.RE i5''€AVAAlr Y
CONSTRUCT/;C3N FEE
101.000-418-000
$940.50
PLAN CHECK FEL
101-000-439-318
11779.70
MI CRKWI `".AL 1EE
101.000-421-000
$9 .50
ELECTRICAL T%Z
101-000—M-000
$133.%
PLIUMB1140 FEE
101-000.419>000
$174,50
STRONG tAOTIM? FEr - RESID
1.11-000-241.000
$)8.50
OkADING FET
101-000-X4223.000
$15100
I;tE' E-LOPI:>,? IMPACT IM,
$2,405.00
:1:313-TMAL COMTM1C'°1`1C9N AND )'Z. AN' ('3MOK V4,585.26
LEW PRE -PAW FEED $0100
`1 A 0
3'! ]l T t;:ES ll?'C E NOW 94l M26
G 8 2004
RECEIPT DATE BY tTA FIN PECTOR
i/ ,V
INSPECTION RECORD
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs
MECHANICAL APPROVALS
Underground Ducts
Forms & Footings
_ _
Ducts
Slab Grade
_ _ _ _ _
Return Air
Steel
_, _ _
Combustion Air
Roof Deck
Exhaust Fans
_
O.K. to Wrap
Framing
Insulation
i
_
F.A.U.
Compressor
Vents
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall -Int. Lath
t—
Final
T 'C
Final
-
POOLS - SPAS
BLOCKWALL
-
APPROVAL '
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP OVA S
Gas Test
Electric Final
Waste Lines
_ 1-
Heater Final
Water Piping
Plumbing Top OutEquipment
lumbing Final
Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
Gas Test
_
/
Encapsulation
Appliances
Final
COMMENTS:
Final
_
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring —
Lour Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)