0005-181 (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 H1C 10/31/7(
Dater. 2,11 .4 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 STAT!: FUND Policy No. . 467_99-0000220
(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: " lzr r . W Applicant-
Warning:
pplicant 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) -4�*'�/`,,�- Date •'
u.>: .•. oma, .�
Y '
BUILDING PERMIT PERMIT#
�������'
DATE fj VALUATIONLOT TRACT
1 259 3
! l 11 1,12 $i �f,9�. {� 3,1
JOB SITE I
APN
ADDRESS 44-w5C.Amy rLAcmo
P�tY4 �f81-I2i
OWNER
CONTRACTOR / DESIGNER / EN (NEER
OLIPHAIN-r AND VM-T.LWS ASSOC., IKC.
OrAP'PTAN f AND WifXTAMS ASSOC., INC.
7'7.900 A.V.k• N=4 OF THE STA=e
77-900 AV1 NIX OF THE S7 AVE3
PALM! DESUff CA VZ211
PALM TSESEW CA 92211
(760)345,,2026 CI31,4 5203
USE OF PERMIT
ffROItX ri1�lLY DWi i4
S:PAL r 31 PLAN 2AR./ PERMIT I: OES NOT.1NCLUDL BLD ;'K'dvA,LL OR
POO1. ALL OTHER PYFkMITS REFLFCT A 7504 RY,,DfJCT10N TO PLAN
CHECK FEB FOR MULTIPLE ISSUANCZ OF SAME PLP.N TYPE.
TRACT CONSTR'UCTI(YN 2x210,00 SF .
PORCHIPATIO 150.00 S1;
GARAOUCARPORTCU) IZ700,80
EVER"n D C0917 0T' Cf3N.S7RUC `T0,11
134,699A10
I> 1mffr bi�m SOMMMY
CONSTRUCTION FEE 101-00.0.418-000 5762,00
PLAW CHECK FF 1:01-000-439-318 059.09
MECHANICAL FRF 101 000-4.21-000 553.50
ELECTRICAL FRE 101-000-420-000 $147.51,
PLUMBING PER 101.000-419-040 �i5d,°1S
STRONG MOT1014 P'9Z • .T3f>;.S10 101-000-241-000 $1.3.47
C3RAUINO FEE 101-000-42.1-000 f $2$.00
DEVEZIPF.R. WPACT 11tZ $1e907.4t►
e
311:13-TVIAL COWJ1R1TCT'tOK AND PLAN CIP. CK
$3,227.61
.P PAID 1'1=13
$0.00
TOTAL PIUKAffIr FEES PkJE NOW
t
RECEIPT
DATE/7,
B� IJP.
iii
DATE FINALED
INSPECTOR
1`J �
y
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs _ ��-
c►J
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
SteelIze
Combustion Air
Roof Deck
(ea
Exhaust Fans
O.K to Wrap
�(_L
F.A.U.
Framing
Insulation
Qaf-�f�
_I2�
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
14 4
Drywall - Int. Lath
J
1 --tio1- Ow
4SOCL_ 71015* cow
Final/
Final
POOLS - SPAS
BLOCKWA
PROVALS
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
oa
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans_
Sewer Lateral
O.K. for Finish Plaster
Pool Cover
Encapsulation
Sewer Connection
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
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 �7
Final
Utility Notice (Perm) —