0005-199 (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 InC 10/31/2(
Date - / Signature of Contractor -
v
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 9 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.
(k.JO have and will maintain workers' compensation insurance, as required by
S ction 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 FU14D 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 provisions.
Date: tLygl !/_)i Applicant -,Warning: Failure 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 r
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)J/ !f/i% . /!�_ Date`► �w'
6'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 00.9-1 9 TRACT
$134,698M 112 25953 '
JOB SITE
ADDRESS W_4yj CALIXpRoSp.Li:1<.o
APN
32 -0,21
OWNER
CONTRACTOR / DESIGNER / EN (NEER
O WT3MT J*M WI]XIAMS ASSOC., 114C.
OL P14AN 1 AND WR "iS Pasoc., INC,
77-900 AVENUE OF THE STATES
77-•900 aA`JM4U E OPTRE STATES
PALM DESiT' CA, 92211
PALM DESERT CA 42211
(760)345.2626 CEL# 5203
USE OF PERMIT
SWOLE 1%A'hfl 5r DWMIN0
SFD-LOT 111 PLAN 2CR ! PERMIT T DOES NOT INCLUDE BLOCK: �Jtft3L1.
OR POO& ALL OTHER PERMITS RLFLW f n% keMUCTIOPt TO PLAN
CHECK 'ME FOR MULTIPLE ISSUANCE OF SAME k"I..AN `i'YPF_
TRACT CUNSTRUCTION 212.10.00 SA .
PORC:HtI ATIO 130.00 MF
0ARAGU ARPORI (SF)
3K5T1bAATXD COST OF CO:NST.RUCnON
234,613SAW
PERM FEE SUMMARY
CONSTRUCTION FU 101.000.418-000
PLAN CHECK F'EE 1:01-000-439-3 t 8 $1%08
MECHANICAL FRE 101-000A421-000 $33,30
ELLC'1 WCAL FLOE 101-400-420-000 $117.61.
PLUMBING FEE 101-000.419.000 $1159.7'5
STRONG MOTION I -BE - REZ11) 101.000-241.000 313.A7
OR ADIWO FIFb 301-0001-423-000 30.00
DE -VE- .OPXR IMPACT SEE $1,9Ct?.On
�3i3i3-TC)�.AL CON 1f LTC' 101NAND P.1"..t�.'t�' GE�E�
X3,22'9.61
1YISS PRE-PA.i i7 3W3
$0.00
JAN 12 2001
Uut
RECEIPT
DATE }
BY- `_
DATE FINALED
INSPECTOR
-U'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings :
Slab Grade
.a �— ��"
�f--
Underground Ducts
Ducts
Return Air
Steel
Combustion Air
Roof Deck
S �'� ��
Exhaust Fans
OX to Wrap
.�F.A.U.
Framing
Compressor
Insulation
Z2vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall'
Exterior Lath
_
Drywall - Int. Lath
Final
Final ¢—�Cp-
BLOCKWALL APPROVALS
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 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
Sewer Connection
6 �j�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final off--fj
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: