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9803-218 (SFD)1K. 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 6%10545 1 d�30/l$ /ate �✓� C Signature of Contractor C E 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. `.TAIT. FUND 033-97-12.34 (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 Bode, I shall forthwith comply with those prom io ,,Date: Applicant - Warning: 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. '..,,,c1: Each person upon whose behalf thisapplication 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 is 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 ffo In©spection purposes. SignaturA(Owner/Agent) b a're BUILDING PERMIT PERMIT# 9CONTROL#9803-21S / DATE f VALUATION $200,892.449 LOT +lw _ TRACT ST�n 81�Q rt ~1 jJl�`i', s[� Y �� y�i JOB SITE ' lii 640 �,:].�FLE PINLS DR. APN 769- "" 042 ADDRESS OWNER / DESIGNER / ENGINEER 3�..Tt+ 1 .EIONIES L LC, _RlT I1VT.;'1'i&3-NtS INC. LLC P.O. Er)X 810 1425 E. UNIM'SiTY MNE 1A QUINTA CA 922253 I`140EM A7 $.5031 (602057-106 CBL# 390-0 USE OF PERMIT' y R IsVD PLAN FO8 - SFD - RJ`I' t•1C1MES .1,A QI31NTA. FA112 WAYS APR 0 9 1998 ITT Q LA OU @ NUA MSTO.M CONSTRUCTION 2,431.00 SF POR HMI XTIO 05.60 9F C3ARAC rixARPOR'T 4%.00 �F { M � ESTIMA U D COST O C( NSTRUCTION x1111i3t9x.1191 PERMBT FEE SUMMARY CONSTRUCTION F FF 101-000-4184910 $99:3.00 PLAN CI ECK F EE 101-000-439-318 $311.117 MCKMICA.L saE:.E 101 -OW -:12.1.-000 $98.50 ELwc"r 1CA1..: h`f� 101-000-420-000 51.1,151 PLtTNiBl"NO FEE 101-000.419-.000 $156.50 STI(ONG NiM ION FEE, - RE SID 101-000-241-000 $20.09 GRADING FM 101.-000-423-000 $20.00 1'fvhRASTR.WFUR.E FR4 225 -ON -443-342 54,479.07 ART -IN PUBLIC PLACES-'RESIr'701-000-255-000 i252.d3 SUB -TOTAL CUNSMUU110N AND F'.1,AN CHECK $e,984.37 TOTAL, P'EitMIT FEEN DUENOM'V Sl�,$ld4.37 v�4P RECEIPT DATE BY �% DATE FINALED INSPECTOR . 3 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel 'Combustion Ail Roof Deck Exhaust Fans O. K. 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 BLOC KWALL APPROVALS' POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground PI . 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 i Final Utility Notice (Perm) COMMENTS:. , ••