0306-490 (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
,Date Y '4 Signature of Contractor
OWNER-BUILDERYDECLARATION
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 sU79 )'"UND Policy No. V;* 1414•'03
(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 o the Labor
Code, I shall forthwith comply with those provisions.
ie: �.•. t _ • Applicant
Warning: Failure to secure WoArs' 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, Inde
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and v
work is not commenced within 180 days from date of issuance of s h
permit, or cessation of work for 180 days will subject permit to cancellat
I certify that I have read this application and state that the above informatio is
correct. I agree to comply with all City, and State laws relating to the build g
construction, and hereby authorize representatives of this City to enter u
the above-mentioned property for inspection purposes. ,r
� j
Signature (Owner/Agent) �r i�%'� ' -_a., _ J !� Date
BUILDING PERMIT PERMIT1
DATE VALUATION t�iyao=l LOTTRACTJOB
a ORDAPN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN &NEER
JA iZpwv%,Y_,YJ1qu" -.10
.8. WC.
31-005 EFI ., T31
5005 Ciel U "Ort-, BI
.ALTA 8RRDTQ F�A. 2 a
Ad.M S AtC?S C:oA �?tis
USE OF PERMIT
0rY33ka'
a1�cW�AAJ a CA. 91 1(%ark( di 4/1. Ae If \. •:rt7Y lu uI,I�,faeF... ,
ryK.y YCt7I:.R\rd(YJ,.,TA pI•/�N/:�a�7•�1d
tV7 LLS, P001, 'PIP L OR :�S'LAF./ 1[:t!'�tA r A",Y�.tiPROACH .
1R.ACT 41511100 OF
.t.3�.�.%9.AY.6�ii•' b� .8Tn4. 4v L3.4?SiLyRI�LGrti ",L .
YK -1l -��it11E cCo�9. 6s�M..:
✓ '
0y>..,.};
ff
101A 11 RE 101-000,4121-000 tUf
R1,WT. R1(7A1.,, Ptaat 101-000-1F«i1-000
A 3i F3T41C� >y 101•:0100-:t I V000J �'tw4,`;✓
STF2j�Jy;dtf '1C21J 'i7i;i . k .�iL i3 101-000
r1 �.ytb7
±�,�+,xJl�°!�.1 S,S.jfs. � (31 "v495J^'i��"•1V`�= $4'�.0'?
f139'i�`'� S .l:JZ.BFIII^t1;°T 72VC's.CD
3 'I3=.1v3'YX CrryMTRU'CTRW MD 1''IA%Ilf C1':3'�C"i�:
^��lRe<M1.d�ah`3
1DP=
10.00
e
TOT41. FERMITVYXIF DUE' NOW
_
AUG 112003
CF LA QUINTA
IA C
F ANCE- DEPT'
RECEIPT
DATE
BY
DA FINAL SPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-- t
Ducts
Slab Grade
Return Air
Steel
- %-
Combustion Air
Roof Deck
!
xhaust Fans
O.K. to Wrap
F.A.U.
Framing
_
Compressor IL
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
i
Final
Final
BLOCKWALL APPROVAL
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
A
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 100
Utility Notice (Gas)
ELECTRICAL APPR VAL
Temp. Power Pole
Underground Conduit
Rough Wiring /
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles 40011,
G.F.I.
2000,
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
I.0, "`t -
`J'
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
606486 B 11130/0Z
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 STATE FUND Policy No. 1705624-03
(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
030"90
DATE VALUATION $14+5,382.20 LOT 118 TRACT 29323-1
JOB ADDRESS 43-732 CO= DEL ORO
P"
A 609-380-023
OWNER
CONTRACTOR /DESIGNER / EN INEER
LA QUNTA DUNES 350
CORNERSTONE DEVELOPERS, INC.
5 005 CALLS RAPHAEL, STE. B 1
5 005 CALLE SAN RAPHAEL, STE, B 1
PALM SPRINGS CA 92264
PALM SPRINGS CA 92264
(760)325-4289 CBL# 6867
USE OF PERMIT
SINGLE FAMILY DWELLING
WALLS, POOL, SPA OR DRIVEWAY APPROACH
TRACT CONSTRUCTION 2,511.00 SF
PORCH/PATIO 53.00 SF
GARAGE/CARPORT 425,00 SF
ESTIMATED COSH' OF CONSTRUCTION
145,382 20
PERIVIIT FET SUA04ARY
CONSTRUCTION FEE 101.000.418.000 $800150
PLAN CHECK FEE 101-000-439-318 $659.39
MECHANICAL FEE 101-000-421.000 $53,50
ELECTRICAL FEE 101-000-420-000 $129.89
PLUMBING} FEE 101.000-419-000 $164.75
STRONO MOTION FEE - RESID 101-000-241-000 $14.54
GRADING FEE 101-000-423-000 $15.00
DEVELOPER IMPACT FEE $7,405.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,242.57
• LESS PRE -PAID FEES
$0.00
TOTAL PERIVIlT FEES DUE NOW
$4,242.57
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR