0212-057 (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
183503 B1 C10 HIC 8/31104
Date 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
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 EXEMPT 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: 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
1 1
BUILDING PERMIT PERMIT#
0212-057
DATE VALUATION $397,380.90 LOT 27 TRACT 29147-1
JOB SITE
ADDRESS 57-630 BALLYBUM014
APN 761-850-002
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WEISKOPF PARTNERS, LLC
KAHUILLA CONSTRUCTION INC
80-070 CHANTICLEER
78-070 CADIZ
LAQUINTA CA 92253
LAQUINTA CA 92253
(760)564-4832 CBL# 3237
USE OF PERMIT
SINGLE FAA/IIL.Y DWELLING
SFD - LOT 27, PLAN 2B. PERMIT DOES NOT INCLUDE BLOCK WALLS,
POOL, SPA OR DRIVEWAY APPROACH
CUSTOM CONSTRUCTION 4,732.00 SF
PORCHIPATIO 1,113.00 SF
GARAGEICARPORT 712,00 SF
ESTIMATED COST OF CONSTRUCTION
397,380.90
PERMIT FEE SUMMARY
CONSTRUCTION FEE 101-000-418-000 $1,682,50
PLAN CHECK FEE 101-000-439-318 $1,353.71
MECHANICAL FEE 101-000-421-000 $137.00
ELECTRICAL FEE 101-000-420-000 $232.36
PLUMBI140 FEE 101-000-419.000 $233,75
STRONO MOTION FEE - RESID 101-000-241-000 $39.74
GRADING FEE 101.000-423-000 $15,00
DEVELOPER IMPACT FEE $2,405.00
ART IN PUBLIC PLACES - RESIE 270-000.445-000 $493,45
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$6,592.57
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$6,592.37
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
SPECIAL INSPECTION SERVICE
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 TRUCT. STEEL ASSEMBLY ❑
❑ POST TENSIONED CONCRETE ❑ ASPHALT "BOTHERr, L/!(
❑ REINFORCED MASONRY ❑ FIRE PROOFING
JOB LOCATION QULA�iY'i
REPORT SEQUENCE N0.
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PERMIT NO.
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COPY SENT TO CLIENT ❑
CONTINUED ON NEXT PAGE O
PAGE OF
CERTIFICATION OF COMPLIANCE
I HEREBY CERTIFY THAT I HAVE INSPECTED TO THE BEST OF MV
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.
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SON TUBE OF REGISTERE SPECT R 7_��
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ATE OF REPORT REGISTER NUMBER