0305-113 (SFD)61
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
7!' 28 4 131 0 08M 1/2117
Date � �• Signature of Contractor i A -
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- provide d 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 REPUILIC 1N1:91WQT' Policy No. 18671681
(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"l should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code,qshII forthwith comply wit4J. ose provisions.Date:j ) / 4pplicantSC n!Warnig:Fail�lre,to secure Workers Compensatigri'cdveerage is unlawful and
shall subject an employer to criminal penalties and ciGil-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.
r�Signature (Owner/Agent) ~' ✓�.�A AYDate n
BUILDING PERMIT PERMIT#
G30&113
DATE VALUATION LOTe6
TRACT 29323-1
JOB SITE
ADDRESS 751-635 CO.R'rX WAWA
APN
609 .3WOLI
OWNER
CONTRACTOR / DESIGNER / ENGINEER
P6mEROSx>`701es n, n3L.
PON3DE'F O&A ROMF3 N INC
6671 OWM40 DRM
400 S. FARREA1'.r DDR. SURE B 103
Mr,"SAISUON CA
PALM SPR.1'}+1G8 CA 92262
(703)187-7114 MIX— 2340
USE OF PERMIT
,.
UNC -1-9 YAWLY 1j a71acra
37D — LOT .26 PLAN 3i'sX9- PIAN DOME- tdOT DICLUDF BI..00K-INALIA
P004 SPA OR'DRI"ij''MV.&Y API'I3O:A.CH
TRACT CONSTRUC:TIO14 3,053.00 SF+
PORCIi ATIO..'.` 500.00 SIS
0ARAGUCA42: 0RT 681.00 SF
i
Ni SMI rED COST OF C:ONSTRUCIJON
I&S-375 50
k'xt3fMM FEE ST34M ,R Y
CONSTRUCTION FEE 101-000-X418.000 $040.50
PIA14 CHECK FEL 101-000-439-318 L7779,10
MECHANICAL FEE 101.000-421.000 $98.50
ELS TRICA I, 'MIX 101-000-420-000 $153.98
PLUIt BIWO FEE 161.•000.419.000 1174,50 .
STRONG MOTION FEE • RYSID 101-000-M-000 $19.59
CRADIV40 FEF 101-000.4.23.000 %15100
DEVELOPER IMPACTFEE
ff M -TOTAL t:.01WfR :3't'�'!T01, AND PLAN CH=
$s4,�Fi5.2C
.L t 03 PRE -PAD fEES
$0.00
Q' L P RNI"L' YMIS DUE NOW
$4,59526
JUN 06 1003
CITYOF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY
D LE
I PECTOR
t - f_• "
i,
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
I DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Ah
Underground Ducts
Forms & Footings
Ducts
Slab GradeReturnAir
— —
Steel
r
Combustion Air
Roof Deck
✓
Exhaust Fans
OX to Wrap
F.A.U.
Framing411
Compressor
Insulation
c , 3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
95 _ O
Drywall - Int. Lath
Final
Final
BLOCKWA
L 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 AP`VA L
Gas Test
Electric Final
Waste Lines
Neater 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)
ELECTRIC
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
Final
Utility Notice (Perm)
APPROVALS
COMMENTS: