0005-196 (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
6W I Il B .UIC 10/31 2(
Date A-L.":F C21 Signature of Contractor 4! ;I_
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
Stiction 3706 of the Labor Code, for the performance of the work for which this
permit is issued: My, workers' compensation insurance carrier & policy no. are:
Carver STATE FUND Policy No. 467-99-0000J20
:.(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 pro ns
Date: hl&� 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 pursuar t 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 urposeso
Signature (Owner/Agent) d JX/z. Date/11
4
BUILDING PERMIT PERMITlt
DATE VALUATION LOT OMS -196 TRACT
�'
109 d�53
JOB SITE
ADDRESS 7
9-391 S> Ta +E F.�0,Sp=0
APN
604-328-0118
OWNER
CONTRACTOR / DESIGNER / EN (NEER
O1JPMWr AISM VVU 1AIM ASSOC, WC.
OI;I'PRANT.PWi: Wi .'FtWS ASSOC, WC.
77-4091XVIU i OF- TUE STATES
17.900 AV TMS OF T]N $TAM
PALM DE3IK3T CA 92211
PALM DFSFMT CA 92211
0760)34.5.2.626 CIEU, X203
USE OF PERMIT
18MG.L:E FA.NJL`.t.' DVMANG
SFD.LO T 1.09 3A OL AN t'P.ERMIT DOS! NOT INCLUDE BLOCK WALL Ok
POOL, ALL OTHER :PEW"I REFLECT 75% iy.E DUC"TION TO PLAN CHECK'
FFE FOR M UL: IRLE ISSUANCN OF SAME PLAN TYPE.
TRXCT Ct NXTRUCTtaN %292.00 SF .
FCIRC:ItlP.ATIO 120,00 Sig
OATMMUC;ARPORT (917) 12,504.30
ES'rl.l"'TED.COS' OT' COF°M i7UC110H
I* rims
PMUMIFni S'iJ.tillMA.iRY
CONSTRUCTION 1E1r 101.000.418.000 $177610
PLfal CHECK VES 101 -000-4"-31 R $162.86
MECHANICAL FEE 101-0013.4.21.000 X86,00
ELECTRICAL PES 101-000-420-000 $150.49
PLUMBING FEE 101-000.419.000 $169.30
STRt'3:rlCI MOTION PRL - RESID 101-000-24'1-000 $13.06
GRA- DINO FEE 1.01.000-423-000 $20,00
1,3EV}pL€FPL''R IMPACT FEE $451"00
- HK
4 SL."a8-TO'.1Ai; CONST&LYC'�C)N .0M l -T AX CPIG;CK
z e. .t LUDS PRE -PAID VIMS
$0.00
I'D
(
TOTAL F I VERWrr, fr6 DUE NIDW
JAN 12 2001
ulu
RECEIPT
DATE 1 j
BY,
DATE FINALED .
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_
`� (}7
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
y,
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. Lathe
Final
Final
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 LinesHeater
Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_ /'S�
Pool Cover
Sewer Connection
_
Encapsulation
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
Final
/7
Utility Notice (Perm)
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