0005-198 (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 RIC 0/31/2(
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 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:
CarrierSTATE O 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 37 0 of the Labor
Code, I shall forthwith comply with those p ov' ions. '�P
Date: a /2L_ Applicant 4 r; '
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 in pe p�ur,ose .
Signature (Owner/Agent)�l /� / i7A 1�?Date Z• Q
r , v
BUILDING PERMIT. PERMIT#
}'
DATE VALUATION LOT TRACT
fildY�, 7 l.p0 111 7-1953
JOB SITE
ADDRESS 7941.9 CAS PRO&PERO
APN
.604-3211 20
OWNER
CONTRACTOR/DESIGNER/EN (NEER
011PHA.NT' AIDS WRLIAMS ASSOC., WC.
OL1PHANT AND WILLIAMS ASSOC., INC.
77.900.AVENUE OF UIE STA7.'ES
77.900 AVENUE Olt1TIE 2MATES
PALIA DESERT Cis. 92211
ppjAol D + S WI r CA 92211
(760)343.2626 owl, 3203
USE OF PERMIT
MLLE I?AI+/MY Dwmi- G
S D.LC.Y1' 111 PLAN 1C ! P>kRVIII' t OTISS NUr INCLUDE BLOCK WALL OR
POOL, ALI, OTHER PFUR S REYLWT 7S% REDUCTION TO PLAN CHECK,
FEE FOR .AUL TIPLE ISSUANCE OF SAME PLAN TYPE.
TRACT CONOTRUCTION 1,i36.t10 fill
PORCHIPATIO :18.00 Sir
43A.F1AGWARPORT tarsi 9,"71l.BtI
If;5Tn"'Im COST OF CON ri°F UC"1'IC)P•1'
104,757so
CONSTRUCTION FYZ 101.0005418-000 $657.00
PLAN CHECK FIS 101-000-439-318 $140.10
MECHANICAL FEE 1011,000.421-000 147.00
L'LWTRICAL FETS 101-000-420-000 $129.19
PLUMBING FEE 101.000.419-000 S1S8.'
STRONG MOTION FEE - R SIU 101-000-241-000
eRADING F.ER 101-000-4254-000 20.00
DEVELOPER IMPACT FEE 111.,9o7.,(f[t
SXM-TOTAL CONS�f.C'[TM. 0,,14 AND PLAN CFEC'K.
$3,068.60
.. LKSS PRF-PAED FRW
$0.00
VOID
�T.AL r' Dt'
JAN 12 2001 .Ta Now
� Y 17_ t=A. UuO h .
RECEIPT
DATEBYr
r;
DATE FINALED
INSPECTOR
II!?/,,I
ISA
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
ILAra TTT
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
_ _
��
F.A.U.
Framing
Compressor
Insulation
Vents
_ _
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
Of�(
POOLS - SPAS
BLOCKWALL APPROVALS
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
12yp ed, ,e—
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
�-
Pool Cover
Sewer Connection
_
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)U
�..�
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)