0005-185 (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
697117 B FITC 1QAY1/2(
Date % /Z 0 Signature of Contracto
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
SecIon 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 STATg MIL) Policy No. 467-99.8000120
(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 3706 of the Labor
Code, I shall fgrthwith comply with those prov' io ! j
Date: D Applicanl4 22_g
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 e
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 suchl"
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 upon5
the above-mentioned property forpup uses..
Signature (Owner/Agent inspectio ter-" Date /2 G
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 00 `YSS TRACT
JOB SITE _�]:APN
ADDRESS 44 - C. mz PLAL.O
W41 -328-W/
OWNER
CONTRACTOR / DESIGNER / ENGINEER
0UPIil+,I3T ANIS WIz..;f LAMS MSOCC., WC.
0TX*LA , '.A131) VM-LIAMS AR: OC., INC..
77-900 AVENUE OF TFIE STATES
77.900 A =- W T V, V1`P17.S
PALM 1))zs"MW CA 92211
RALM T;,F.MT :'CA 92211
(360)315.2626 (OWN 5203
USE OF PERMIT
O1 01Y, FAIL DWFJ-LWG
5110 -LOT 9k PLAN 3CR / PERMIT ]DOES NOT'rNCLUDE BLOCK, WALL OR
P001, ALL OTHER PERMITS REFLECT ?V* RED ICTION TO PLAN CHECK
FEE VOO.R MULTIPLE ISSUA14CE OF SAME PLAN TYPIL. t
TRACT CONURUC"-TION x`192,00 SF
PORCHIPATIO 120.00 SP
0ARAINICARPOR T (8F) 12,504.80
ESM11A[A's COM.' OF C0VS'11ZUCli019
138,556.40
P.is'RM1f't° FEE A"RY
CONSTRUCT?ON TRE 101-000.418.000
PLAN C;.HI?XX FRE 101-000-439-318 �i63,8b
MECHANICAL FES: 101.000.421.000 $66.30 "
ELECTRICAL IEEE 101-000-420-000 $t50.48
PLUMUINO M- E 101.000-419.000 SIKSO
STRI0440 MOTION FFY, - "-SID 101-000-241-000 $13.96
ORADING FEE 1.01-000-423.000 120.00
DEVELOPER IMPACT PELF $1,901.00
w•
n
SUB T071 AL CON'S'T XTC'CION' AND PUN CHi?C &
$3,266.20
LESS 1?RR-k'AlD FEW
${9.00
'14U'I'.A.LQ PMW M15 DUE ff0W
9336630
JAN 12 2001
a,--
dlTY �� !OU���
6
y �
-
RECEIPT
DATE f i i
BY�1;_ ,�
DAT FINALE
INSPECTOR
O
L
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
6UILDING APPROVALS
MECHANICAL APPROVALS
Set Backs {
Underground Ducts
_
Forms & Footings ; I 50 "'CCCDucts
Slab Grade I f
Return Air
Steel +. {
Combustion Air
Roof Deck I I 0 C -P
Exhaust Fans
0. K. to Wrap 11
F.A.U.
_Z
Framing ; I �� "
Compressor
Insulation
Vents
Fireplace P.L. I
Grills
Fireplace T.O. ' i
Fans & Controls
Party Wali Insulation"
Condensate Lines
Party Wall Firewall I I
Exterior Lath I I
Drywall - Int. Lath I I CJ(
i!
+f
I (
Final
Fina} II
POOLS - SPAS
BLOC A, I PPROVALS
steel
Set Backs I I
Electric Bond
Footings ; {
Main Drain
Bond Beam i I
Approval to Cover
11
Equipment Location
] !
Underground Electric
i I
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Waste Lines I f 2 2O J\ CSly
Gas Test
Electric Final
Heater Final
Water Piping {
Plumbing Final
Plumbing Top Out I I
Equipment Enclosure
Shower Pans 1_
O.K. for Finish Plaster
Sewer Lateral I!
Pool Cover
Sewer Connection +, I
Encapsulation
Gas Piping I !
Gas Test I
Appliances l i
i I
Final
II
COMMENTS:
'
;I
I!
Final ; [
Utility Notice (Gas) I {
ELECTRICAL APPROVALS
Temp. Power Pole i I
Underground Conduit
Rough Wiring l
Low Voltage Wiring
Fixtures ; f
Main Service it
Sub Panels 1;
Exterior Receptacles
G.F.I. 1 {
Smoke Detectors j {
Temp. Use of Power
I I
Final ]!
Utility Notice (Perm)