0005-207 (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 :13 PITC /2(
Date It t 1'% 4121 Signature of Contractor � -
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.
?.Jr4I 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 NND Policy No. 467.1/0-0000120
(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 Sectio�n.3700 of the Labor
Code, I shall forthwith comply with those p ovisions ,
Date: x iil 1.1� Applicant s f' y ,,A __
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 employee' $1
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.
q
Signature (Owner/Agent) 4 �o i�� Date
�tf jar,
BUILDING PERMIT PERMIT#
OOW-207
DATE VALUATION LOT TRACT
120 25953
JOB SITE�T
APN
ADDRESS
_3M �v<.�Aa TAI e� ftO
604-3?.€ "
OWNER
CONTRACTOR/DESIGNER/EN &NEER
OLxPFIANT AND W 11, ABtM ASSOC., WC.
O%TP-HA>` T AND 1xI1I.LIAMS ASSOC., IWC.
77.900 AVENM Or, THri IWATES
77.900 AV .NUS OF '= ST':A1TS
PALM DE MMT GA 92211
PALM DP.S T CA. 92211
V60)345.2626 CRM 5203
USE OF PERMIT
MGM FAMMY DVW 12TO
S
SFD.LUI' 120 PI.,A13 38111/ PERMIT i O&S' NOT INCLUDE BLOCK WALL
OR F10O ,, A.LL OTHER PERMITI. REFLECT 7S% UIDUC`.t ION TO PUN
CRECK FEE FOR MULTIPLE lFhSUANCZ OF SAME PLAN TYPE.
TRACT CONSTRUCTION 202.0 SF .
PORCWPAT16 120.00 SP
GARAOF)CAi PORT (3F) 12,504,$0
1w:MMA= COST OF COMUMMON
139,566A0
Platwir 11FIE SUMVEARY
CONSTRUCTIO14 FEE 101.000.4-18-000 $714,110
PLAN CHVICK YZE 101 -00(3 -439 -its $162.55
MECi-IA111CAL FEE 101 *01110^421.000 566,30
E;L ECTRlt'>AL FEE .101 -000 -420 -OW $150A9
PLU M1igTHO F&E . 101-000-419.000 $169,50
STIRONO MOTION FEE = RFSID 101-000-241-400 ' $13.815
0RA.DMG FEE 101--MO-423-11100 $20.00
DEVELOPER. IMPACT Y E $1,907,0113
'h
SiJ:vrcn;. r.601481 -RUC 014 AWD PIAN CHYCK
$3,.266,20
LESS PRE1-PA1D,1: +S
30.00
T OTA- PFJMff FEES DUE OVV
s� 0
Q.
JPS � �� � •
b.
RECEIPT
DATE ju.
BY# y.
DATE FINALED
INSPECTOR
.
f �` t
INSPECTION RECORD
OPERATION
L,
DATE
T 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
_
Vents
Fireplace P.L.
Grills
Fireplace T.Q.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. 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
_ _ _ _
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
Finalelf
Utility Notice (Perm)
7 _11—
X -7-1,11—
L, L.