9806-256 (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 intfull force and effect. `
License # Lic. Class Exp. Date'
ti�li,i.1. E _
ate J ��i �� Signature of Contractor - r11 `�'
P� <
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 (Seca 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 Policy No. +
(This section nee not be completed if the permit valuation is for., 100 Ol0 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
C9de, I shall forthwith comply with those provisions r
t,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. r
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 alf•Cay, 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. f �.
I
/nature (Owner/Ageht) Date—,;
BUILDING PERMIT PERMIT#
DATE VALUATION LOT �341f-25f► � TRACT
97
$ .134,373.110 t 25953
JOB SI
ADDRESS
4,1460-C:ALU; PLACtDO Of
APN
604-+071-007
OWNER _
CONTRACTOR/DESIGNER/ENGINEER
OLIPHANT AND WILLIAMS ASSOC, INC,
OLIPHANT AND WILLIAMS ASSOC., INC.
?7-900 ANM. OF THE STATES
779®0 Atm. OF'THE STATES
PALM DESERT CA 92211
PALM DESERT CA 92211
(760)315.2626 C11L.# 5203
USE OF PERMIT
r,
S'FiD - P14 1, LOT 97; PLA& 2C. PERMIT DOES NOT INCLUDE BLOC.
WALLS Olt .POO.t. P11.kN CHECK FEE- REDUCED 75° o .FOR. MULTIPLE
r4.qqYrawrn7 n ...czAmr w Am Tvpy
TRACT M4,STRUCTION Z-2*4.00 SF
PORCH/PAT 10 150,00 SF
GAR AGWCARPOR.`.I 13411,110 SF
E,44T I MATE D COST OQ+ CORi&3'a`tLIC7fWN
134,37:3.181)
PrERllI f' FEE x'31&URS'
CONSTRUCTION FEE 101-000-44£1-000 $7612.00
PLAN CHECK FEE 401-M-439-318 $161.51
NIECRANICAL FEE 101-000-421-000 35330
hC I'1tTCAL :N`EE 101-000-4,20-000 3117.60
PLUA (SING M, , 101.01X-.494= $203.75
STRONG NOTION FEE - "R> SfD 101-000-241-000 $13.44
G1L'kf5fNG FEE 101-000423-000 $20,00
INFRASTRUCTUREFE, 225-000-443-342 $2,978.51
PRFW1SEPLAN � Idl»000-444-3<t5 $25-00
ART ISI PUBLIC PLACES 1,M -3 -ST 701-000-255-000 $85.93
i
..
cd
S 'Bi,�OTAL CONSTRUC11014 AND PLAN CHECK .
$4,451.24
LESS PRI -PAID FEES
$0.311)
),,TOT AL PERMIT FEE,* DUE NOW
$4,451.24
,RECEIPTDATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
e
Underground Ducts
Forms & Footings
Ducts
Slab Grade
4Return
Air
Steel
Combustion Air
Roof Deck
-
Exhaust Fans
0. K. to Wrap
- 3 - 8
F.A.U.
Framing
$ 51--
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
DW.vall - Int. Lath /
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
62
Pool Cover
Sewer Connection
p
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Condtit
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} ;111717 7
COMMENTS: