9808-199 (SFD)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
// /2_424 a 7/31/00
Date 1117, ee(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).
( ) 1, 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.
• tainll:t{il.'iilo�:le+L, Li,�, ' 1�'tiV�;34��0+�`S00
(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 hall forthwith comply with those provisions.
Applicant—
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. Lagree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon +
tthhe,a'bove-mentioned 'property for inspection purposes.
/Signature (Owner/Agent) f —� "�� Data -000' � r
PERMIT # CONTROL #
BUILDING PERMIT
"03-199 r� 5
DATE VALUATION 40 LOT � TRACT 4 �
AsJOB
I f I '^
SITE
ADDRESS 7`9-630 �4� G, A
APN 769-700-005
OWNERi
CONTRACTOR/ DESIGNERENGINEER
an..SryXiI��U.S'NLILC
"17LLLUS ftESIDWHA LClit9t M CT i�1
HaK PL-Abk SXE, 400
5 PAit i�. PLS., SU11% 460
MME CA. !)2,6W
1RMN:1 CA 92614
(714,YZ53-6100 CB1,01 5072
USE OF PERMIT
SINGL1; GAMU, Y DWELLING
177 - IC -01, LCIT14 215, PaIv it DOES NOT DICLUDE BLOCK WALL
OR POOL. PLAN CHECK FEE ,12.f DUC: T.) /:s`:%u:L•OR MIXTIPLE IS$UA.NC , OF
`;A?1AF PLAN Mr.
CtJ�:C�,�41C'i : Siii1C`I3C3�i 3,434.00 SF
POkC RIPA. � IO 302.00 3F
CtE112At� J!'A1t1aCi 'b' 807.00 SF
ESTIMATED COST 01,TONSTRUCTION,
F,:�,4',40
PICIRNa" T V RE SUMMARY
CrONSIMUC IONM 101-000-418-000 SIF 7.5{3
PLAIN CHECK FFE 101-4.0-434-118 5267.2'
WMC NAXICAL FEE 101-000-4A t -000 $130.50
,GFfi'fWCAL F'FIG 101-000420-000 5220.33
PLtdpygt31NG Fee, 101-,000-419-000 $214.5x1
STRO140 M0TJ0N- RF,S1D • 101.4)00-241-000 $29MA
ORWING F1 : 101-4J00�423-4)00 -`
(S�y0�.0+o�3
INCRAS"1RUC�'1"£JCtE � � t 225-000-4� 3,342 � 6joop
AR!r IN PUBLIC PLACES - RESID 701-0001-255-000 1468.36
TAL CON83-'?2f�3G'�r ON AND PI AIN 4aHECK
.T4
T.ESS PRE -PAW FEES
J
IS0.c
NOV 12 1998 TOTAL; PERINOT FEES DIX NOW
58,647.19
'tkcz
RECEIPT
DATE
BY i
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
- Fei
Underground Ducts
Forms & Footings
Ducts
Slab Grade
- g,
Return Air
Steel
Combustion Air
Roof Deck,
Exhaust Fans
O.K to Wrap
- �
F.A.U.
Framing
L�
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 r✓� (C�c
Final til
BLOCKWALL APPROVALS
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 Condult
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
e -
Final
Utility Notice (Perm)
COMMENTS: