0005-204 (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 1HC__4 9f1/2f
Date 2-10 Signature of Contractot'�
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&RC. 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 Ihave 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 KIND 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 provi ion .
Date: L1� Applicant
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 to7
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 purposs.
Signature (Owner/Agent)�'jf Date Z /
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0005-204 TRACT
$1,553$.i3t1 Iii 2593
JOB SITE
ADDRESS 79406 CAL LE ]'R(MER4
APN
OWNER
CONTRACTOR/DESIGNER/EN &NEER
OLPHANT MD WDJJAW ASSOC., INC.
Oi NIHANT AND WItIJAMS ASSOC., INC.
77 -?00 AVENUE OF TkL STATES
77.900 AVENT19 010 THE, UFAIES
PALM DR91MT CA. 92211
PALM DESERT OA 92211
(760)343.2526 C9114. 5203
USE OF PERMIT
=012 FAr'viLY DIKE UN
SF'D,LOT 117 I%I.O 2B / P?"IT DOXw NOT INCLUDE. BLOCK 'WALL OR
POOL ALL OTHER 1 EMITS RC?RACT 73O/4 REDUCTION TO PLAN C.1RM
FETID FOR MULTIPLE ISSUANCE OF.''.AME PLAN TYPE.
TRACT CONSTRUCT101 21210,00 SF
1 OPICH/PATTO 150.00 Six
GARAt'1MARPORT (SP) IZ70 ,30
EsT1"Tv,) COST 01fC011SIRUCOOR
134.6,N.W)
PER7AW FEE HUMTVI RV
CONSTRUCTION FEE 101 -ODD -418.000 VM2,00
PIAN CHECK ME 101.000-439-318 $159.08
MECKMAC,AL WF 101.000.421--000 $33.30
TLLEC`rRICAL fW, 10.1-000-420-000 $147.91
PLUMMO FE9 101-000.419.000 $164:73
STROMO MOTION FEE - Ri?SIE) 101-000-241-0100
ORADNO FEE 101.000-423-000 $20,00
DEVEWPER IMPACT FEE �m1,90'1,00
him--rOT.AL, C°OA1E RCTC'1itJ1tiTARD PLAN CIT9.CK
$3,227.61
L"D FRR,:PA D F
$0.001
;T10TA1, F 3,17 MW FM91,'11'1;X!; N0W
2 20®1
RECE
DATE
BY(p, t
DATE FINALED
INSPECTOR
j(s
.1 . r I , ,:
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
_
Insulation
Fireplace P.L.
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final �. 2 -e/ _
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
2
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
/
Pool Cover
Sewer Connection
_
Q
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final _
Utility Notice (Gas)
ELECTRICAL
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)
APPROVALS
-Z
52
COMMENTS: