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0005-186 (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 597117 B MC 1101311W Date Date Signature of Contractor'�'r-n-�,.�-�4 a .'j 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. >40-1 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. 467-99-0000120 (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 provisigns. Date: Y,ZQ Applican J �{ 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 io, 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) !�//Z%Date f -rz, NIM BUILDING PERMIT PERMIT# 000.486 DATE VALUATIONLOT TRACT $138,556A 99 25-91, JOB SITE ADDRESS 44-700 CALLF PLACIDO APN j 604^:328-•OUh"u r OWNER CONTRACTOR / DESIGNER / ENGINEER r OLSPHA NT.AND WII.LJA`MiS ASSOC., INC. OLIMANT AND WII.�T %At&S .ASSOC., ?NC. 77-900 AVENUI3 OF THL, STAT.E,S 77.900 A:VZtTI~LFE, OF TI -M— UrA lln PALM1:7L,.%Wf CA 92211 PA1:MDESEXT ,CA 92211 (760)345=2626 CBL`J5203 USE OF PERMIT SWOLB FAIt9L►'. Y DVIMUNO SF0,LOT 99 PLAN 3A / PERMIT D1D&,S NOT INCLUDF, BLOCK W.P.M1 OR POOL. ALL OTHER PERMITS RKTKb CT 7:1V5:t EDUCTION TO PUMN CHWK FEE FOR MULTIPLE ISSUANCE OF RAW PLAN TYPE. ; TRACT CONS',IRUCT1CiN 229100 SF . PORCHfPATIO 120.00 SF 0ARAWCARPORT (SFj 12aSO4,H9 EsT.CIUTATED COST OF CONSIlWanoll 139;556A!D P'ERl4m MWhWARY CONSTRUCTION FRE, 101-000-4I6.000 rmoo PLAN f HWX MAA 101-000-439-316 $IC•2.88 JMT CI +YJICt1i.1 B 101-000-421-000 S66,50 LLLCTPJC.AI, FEE 101-000-420-000 Ifi1sU.a0 PLUMB1140 FEF, 101-000.419.000 8169,so STRONG MOTION FEE - RESID 101-000-241 -OaO $13.86 ORADINO ISE, 101.000.423-000 $20.00 DEVELOPER IMPACt FLEE a � F 1 s 9 SUB TGTAL 'C0'9'i'i UC'fJ_ON AM PLAN CHECK. $3,266.20 LESS PRE -PAM FEW S0100 TOTAL MOW FEES DUE -40W 24) JAN 12 2001 .3 •d C v0 LNab UU0 ` RECEIPT DATE ! BYn �..� DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs ; [ Forms & Footings G �P Q?i Underground Ducts Ducts Slab Grade I Return Air Steel ( Combustion Air Roof Deck �H Exhaust Fans OX to Wrap [ S F.A.U. Framing Compressor Insulation' i` Fireplace P.L. [ Q (_'{ t�'0� Vents Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall; Exterior Lath Y/t Drywall - Int. Lath 11 I }; Final Final II -O / BLOCKWALL APPROVALS POOLS - SPAS steel Set Backs ( Electric Bond Footings i I Main Drain Bond Beam i Approval to Cover 11 Equipment Location r Underground Electric i } Underground Plbg. Test Final i { Gas Piping PLUMBING APPROVALS l Gas Test Electric Final Waste Lines 02 Heater Final Water Piping ; I Plumbing Final Plumbing Top Out; Equipment Enclosure Shower Pans [ O.K. for Finish Plaster Sewer Lateral ; i 1 Pool Cover Sewer Connection { Encapsulation Gas Piping I Gas Test ��C Appliances 1, Final I { Final Utility Notice (Gas) I ELECTRICAL APPROVALS Temp. Power Pole I Underground Conduit Rough Wiring I I Low Voltage Wiring Fixtures ] I Main Service I Sub Panels Exterior Receptacles G.F.I. { Smoke Detectors I Temp. Use of Power Final l / Utility Notice (Perm) COMMENTS: