0005-203 (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 BMC 10: w 2(
Date Signature of Contractor,� R
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 STATE FUND Policy No. 467 94-000DJ 20
(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 prervi ions.
Date: f I gl. 1>� Applicant��d •� % , o
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant tot; 4s
any permit issued as a result of this applicaton agrees to, & shall, indemnify .
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not 'commenced within 180 days from date of issuance. of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspections purposes.
Signature (Owner/Agent %� • �' Date �-
Y r/v o SIT ( ,
BUILDING PERMIT PERMIT#
20.3
DATE VALUATION LOT TRACT
S3.&3,5.%A0 116 29953
JOB SITE c�
ADDRESS w-652oC.AI.a�a�+rl�Ov��.EAQ
APN
604-328-IJ..a5
OWNER
CONTRACTOR/[ / EN INEER
OLIPRANT Alm VVI11"U-V.W ASSOC., INC.
OLT PHAli"1' AM) WA'..T; 4MB AS$OC., IWC.
'77.900 AvM4tM- OI+ THE 'ATM
77.900AMUE OF TIE STAM
PA M DESER` ! CA 92211
PALM DESEWf CA 92211
(760)345-2626 CI3O 5203
USE OF PERMIT
SWOLE T:A1.11L ' DWFj.1 .4G
SP'D-W'P 116 PLAN 31;9 / PERMIT VOES NOT 11�CLUDE BLOCK WA.LI, OR
P001 -,ALL OTHER PERM RZMEC l 51A? REDUC ION ` O PLA14 CHECK.
FEL FOR MULTIPLE 1SSUANC , OF SAME PIAN TYPE,
TRACT WNSTRUCT](614 2:292100 �ff
PORClifP'f.T10 170.00 S?
0ARAGE/C.l3.RYORT (ST, 1.21304.90
ES'HMAIXD COS.r OF CONSIERUC1TON
138A%,.40
PF,RMT M SIINriMARY
CONSTRUCTION FEE 101-000.418.000 9'1'46100
PLAN CHECK FEF, 101-000-439-:318 $162.86
MECHANICAL FEE 1011000.42.1.1100 866.E
ELF,,,CTRICAL FEE 1431-00"20-000 $130.48
PLUMB N0 FELE 101.000-419.000 $169150
STIRONG MOTION FEE - RESID 101.000-241.000 $13.35
OR.A1 ING FEE 101-000.42.1-000 $20.00
FDEVEiAPER IMPAt.`.T FEE• $1,s0B.fji�
t'X
4.1 g t
7
SUB -TOTAL. C014 t..i.TG`TT0W AND PLARCIPECK
$:3,266.10
' LESS PRU-PAID M- S
$0,00
TOTAL PEMWIV IMIE8DTJY NOW
RECEIPT D E !
���-
BY-� a
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_ �� O
��
Exhaust Fans
OX to Wrap
_ 1
F.A.U.
Framing
_
Compressor
Insulations
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
_
Drywall - Int. Lath
/
6 -✓— -6%
c9�-
Final
Final
ZZ�J
POOLS - SPAS
BLOCKWALL
A 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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_ _
% ��
J
Pool Cover
Sewer Connection
G�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final 0�19
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
Final
Utility Notice (Perm)il
L>�
Lit-r-140t1J VUIV 1 MMi., 1 Uri NCI�LMnM11UN
I hereby affirm under'.penalty of perjury that I am licensed under provisions of C
tom— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and j
cel W Professionals Code, and my License -Is In full force and effect. ,
C ch . License # ; Uc. Class' Exp. Date
CY to
' �' r 697117 13 Hid . 10/� 2(
Z Date L Signature of Contractor
� p � 0
J U OWNER -BUILDER DECLARATION'
Wa I hereby affirm under penalty of perjury that I am exempt from'the Contractor's
• License Law for the following reason:
Z ( )', 'I, as owner -of the property, or my employees with wages as thelr sole
compensation, will do the work, and the stricture Is not Intended or offered for
sale. (Sec. 7044; Business& Professionals Code).
( ) 1, `'as' owner'of,�the; property; am exclusively contracting with 'licensed
contractors to'construct the. project (Sec. 7044, Business. & Professionals
' Code). ..
'- O I am exempt under Section 8&PC. for this reason
C\IDate Signature of -Owner
Ocm
rn
WORKER'S COMPENSATION gDECLARATION,
9.2 Z II herepy�affirm 'under, penalty of perjury one of.. the following, declarations:
p„ ( )+ 1 have and wiII'mal ntain a -certificate of•consent to self -insure for workers'
Xr'W,LL' t compensation, as provided for. Section 3700 of the Labor Code for the
m � _J? performance of the vyoFk for which this'permlt,is issued.
Q V ����1, ave and will! maintain workers' compensation Insurance, as requin3d by
i'Sectipn 3700 of the 1abor.,Code, for the performance of the work for which this
permit (s issued My' vlrorkers' compensation insurance carrier8 policy no are'
=rt �, z' ('.alder` t•, }�- A P011cy No
1 J ,•ie n ,r ! 8`fATB M. , D Y 467.49-t>000I50 2
r F
-,"-JThis section need not be 'completed if the permit valuation Is for$100.00 or less):
rtify 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
31 ,x f woikers'�compensatlon laws gf Califomia; and agree that if I should become
3, I '••subject;to the workers'.,corripensation"provisions of Sectio 3700 of the Labor
y1, alfa!! forthwith comply with ose p vi' ons.
Date �Z/U/ Applicant '
Wang: Failure to;secure Work
rniers' Compensation co erage is, unlawful and
shall subJect,anemployer to criminal penalties and civil fines up to $100,000, in
{' addition to the cost of compensation, damages as provided for In Section 3706
.of the Labor,Code Interest and attorney's fees.
IMPORTANT `Application Is hereby'mads to the Director of Building and Safety
. for'•a permit subject to : the ` conditions and restrictions set forth' on his
.application. .: i } ,
r •• ' ` 1: Each* person ,upon whose behalf this application is made & each person'at '
Whose request and for whose benefit work is performed under or pursuant to*
any permit Issued as'a result of this applicator agrees to, &shall, Indemnity
& hold harmless the City,of La Quints, its officers, agents and employees.
{ 2. Any permit issued'as a'result of this application becomes null and void if
Arwork ' is not commenced ;within 180 days. from date of issuance of such
,r permit,, or cessation of work for 180 days will subject permit to cancellation.
I;certity that I have read this application and state that the above Information is
• correct. I agree to'comply with all City, and State laws relating to the building -
constructlon, and hereby, authorize representatives of. this City to enter. upon
the above-mentioned property for inspection purpos
� a -Signature (Owner/'Age. Date.yca/,`�"'
,
7 BUILDINGVERMIT` PERMIT,
DATE ; rt ', .
f VALUATION + LOT r TRACT Y�
,• x3953 r ,
.�
, . ,
JAODBDSSIITSES,
7%4W G'Ai.LL *OSP1CItd
OWNER
CONTRACTOR / DESIGNER /ENGINEER
OIDMWT AM WnllAMg iti;40C., INC.'
1A.1j
OLtPHJK n MD ViiL.t."1AI
. ”-9W.AVENUI7 OF THE 31'ATE9
7? -900 AVF1�lUE OF THE tii'A ` .
JPALM DFMT CA 92211•
1 .
PALM DI CT CA % 92111':
�
(7 0)345-2626 CT S? 3203
USE OF PERMIT
,.
IIQ IZ FWLY DWELT,IN(3
'
,r Y'
3RD -LOT f 16'PLAN 3BR! PERMIT DOLS NOT INCLUDE BLOCK WALL OR
POOL. ALL OTHER PERMIT$ Ri„.FLECT 75% REDUCTION TO PLAN CHECK'
FEE FOR MULTIPLE.TSSUANCL► OF SAME PLAN TYPE.., '
' . •1...' try
- - r � ,
TRACT CON18TRUCTION ?541.00 0i t
PORCH/PATIO . 120.00 SF,'
_13ARAGEfCARPORT(OF)
j
23SAWAa
asr ►Tan cogs of connRuano
:• PTRMit' L'FJE 8QMi1�2Y •' , :.. i ; �
� i � # � , .
.'CONSTRUCTION FES -101400-418-000 "- S7M00;
.-PLAN CHECK FEB 101-000-439-318 062:86
.+.
,
•MECHANICAL FER 101.000.421.000. .'S66.50'
_
L1.E'TRI CAL,AEIL 101-000-d2a00o `d�; sTS0.4it
•, /'
�t t
PLUAi1B1N0 FEE 101.POO- !9.000;
STRDNQ MOTION. FU • RES1D <.101 X000-241-DQO' +; ` X13.86.:'
•
ORADINO ` 101.000.423.000 .150.00
;
DEVfP. bPER IMPACT TpEE x$11907.00
1
COw,I'RuenON AND PLM CEI =
$3,26610
' `LESS PRE-PAIDFXf39
$0.00
,PN•,',. (-� PI�RIVaT FE1S8 D�7E ftOiAr• ,
; S��t�t�
RECEIPT
DATE
B
DATE FINALED
INSPECTOR