0212-058 (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
783103 Bi C10mc V31104
/ I
Date Signature of ContractorIV.�'*
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.
(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 $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at':'. -
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify,
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of,such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property..for inspection purposes.
Signature (Owner/Agent) y��
BUILDING PERMIT PERMIT#
���$
?ro
DATE VALUATION LOT
M��'L`
f TRACT
`ice je .,"'i ♦ V147-1
JOB SITEP
ADDRESS r -57-15E6 )RlabY301UNLON `
AN
OWNER r
CONTRACTOR/ DESIGNER/ EN (NEER
KA,Hr:MI-A C:O.1t7STULK"71OR INC;
x^,040`7 D CS Mn, CI MM
7a -r3'7Q CADIZ
LA QuDrm GA 92.253
T.,.& Quwmk CA 922S 3
(760)564.4832 CB1.4 13237
USE OF PERMIT
SISI) • TOT 1?5'KCY1 SNC0.,I. V , iiL,t"CK WALLS,
7k PLAN III. PE1=
P4004 SPA OR. DRIVEWAY A PPROAo!H
CUSTOM Cf: NSTRVCTION 4,364.00,1$7
POPtiC;i!i!i?.J1.TIO 590.01 Far
QtWk0FJC.FiRKDTVF %9 0.0 Is
ESMA".HE'D COUr OF CONSRUMON
563,M)SOI +
CONSTRUCTION = 101-000-418-M S1156111zo
PLA14 CI•IECP:' YVE 101-000-4s'"tr'-318 $1,264.27
MICHANICA1, ME 10) -004.421.000 SI:a0.s0
Z11.41CYRICA1, lirtIt 101 M110t -410-000 $.22I.62
PI.,x TMIDMO KFE 101 -000 -419 -OK 9i;27,75
MTRONO MOTION FEE • RESID 1011-000-241.000 $36.39
OPAD1140 ME 101.000.42.5.000 S20 DO
t34?:C►I7., IOPRIP. ShWhr"'T IMF, g4aL'tC+
ART IN PUBLIC PLAC S - XBRIE 270-000-45, 0000 $400,64
D ° a UISS PM—PAM YM
50100
DEC 1 0 2002 , PERWr EUDUE
CITY OF LA QUINTA
FINANCE DEPT.
S'6,27 , ,2 7
RECEIPT
DATE
BY
TIN
INSP
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings Q.
fa 3
Ducts
Slab Grade
D
Return Air
Steel
Combustion Air
Roof Deck
3 3
Exhaust Fans
O.K to Wrap
F.A.U.
Framing b T6
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
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPRO ALS
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
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
_
Temp. Use of Power
Finalvir_
Utility Notice (Perm)
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
783503 BI C10 MC 8/31/04
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
BUILDING PERMIT PERMIT# -
0212-058
DATE VALUATION $363,$55.00 LOT 28 TRACT 29147-1
JOB SITE
ADDRESS 57-66013ALLY13UNION
APN 761-850-003
OWNER
CONTRACTOR / DESIGNER / ENGINEER
WEISKOPF PARTNERS, LLC
KAHUI LA CONSTRUCTION INC
80-070 CHANTICLEER
78-070 CADIZ
LA QUINTA CA 92253
LA QU=A CA 92253
(760)564-4832 CBL4 3237
USE OF PERMIT
SINGLE FAARLY DWELLING
SFD - LOT 28, PLAN 1B. PERMIT DOES NOT INCLUDE BLOCK WALLS,
POOL, SPA OR DRIVEWAY APPROACH
CUSTOM CONSTRUCTION 4,364.00 SF
PORCH/PATIO 590.00 SF
GARAGE/CARPORT 819.00 SF
ES'TMATED COST OF CONSTRUCTION
363,855.00
PERMIT FEE S1110AARY
CONSTRUCTION FEE 101-000-418-000 $1,563.50
PLAN CHECK FEE 101-000-439-318 $1,262.87
MECHANICAL FEE 101-000-421-000 $130.50
ELECTRICAL FEE 101-000-420-000 $221.62
PLUMBING FEE 101-000-419.000 $227.75
STRONG MOTION FEE - RESID 101-000-241-000 $36.39
GRADING FEE 101-000.423-000 $20.00
DEVELOPER IMPACT FEE $2,405.00
ART IN PUBLIC PLACES - RESIL 270-000-445-000 $409,64
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$6,277.27
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$6,277.27
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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