0005-194 (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 E WC 10/3112C
Date 0 4lG i 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.
( I have and will maintain workers' compensation insurance, as required by
S ction 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 :PlftlD Policy No. A.67-99-11000120
(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 thoro isioQAsY
Date: - // Applicant%%�� r i/ / /7
y p - vh'
Warning: Failure to secure Workers' Compensation co4e%rage 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 inspection purposes.
Signature (Owner/Agent)`91l/ifDate—! 11-219:501
BUILDING PERMIT PERMITT#
thy
�J 194
DATE VALUATION LOT TRACT
,'9dia 107 75953
JOB SITE
ADDRESS % -&,Fa CALLE Pp U
,()Sp=o
APN
E90Qr . 2"1ss
OWNER
CONTRACTOR / DESIGNER / EN INEER
OLMU'MT A�M VM.UAQ ffl ASSOC., INC.
OLWFI,AW.A)SM VIJnl S ASSOC., 'INC.
'77-900 AVEt=1 OF THE STAlE, 3
77.900 AVENUE OF THE tTrATE, 5
,PALM DR:0. T CA 92211
PALM D1±:ffW CA 92211
('760)345-2626 CZ' .5203
USE OF PERMIT
S.WG E FA— MY D 6
SPD -LOT 107 ELAN SBR! PERMIT DOES NOT 1'NCLUDE BLOCK 'WALL OR
POOL, ALL, OTHER PERMITS RFFLE07 730/.119DUCTION TO PIX?i CHF.'CK
FEE FOR MULTiPIZ ISSUANCE OV SAME PLAN °P'4'PF_
TRACT CONSTRUCTION 2,430,00 8F .
PORCH/PATIO ,' 7t3,i10 ESP
QA13AOEICARPOR.T
Ii;L4iVU19 ED COM' OF CONSTRUC'i"!:4JN
14W9A0
PST' Fn 9r3NrK 1 Y
CONSTRUCTION FRE 101-000-418-000 X31 S.r74
PLAN CHECK FEE 101.000-4.19-318 $167.99
MECHANICAL FEE 101-000.421.000 $60.00
ELECTRICAL FEE 101-000-420-000 $149.42
PLUMBIN(O .".L 101.000.419.000 $169.00
STRON'O MOTION FEE - RMID 101-000-241-000 $1.4.96
GRADrNG RLL 101-000-423-000 2ti.t10
1' EVERLOPER IMPACT FEE $1,9p1.90
a`S
' f
V 4 �
,r SUD-T0TiJ. COX=. CT`1ON' AND PIAN CHECK
S3,289.27
r"B l�12E=Pl�TI� f7i.q
$0.00
r TOTAL 1'ERMU MMS DUE NOW
JAN 12 2001,
RECEIPT {
DATE /
J ,
BY ?
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
Set Backs
Forms & Footings
Slab Grade
APPROVALS
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
_
�,
F.A.U.
Framing
ZS�� �/�
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 C
FinalQj �2
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
Z �+,
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
_ \ K_
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
LIX
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 ���d
Utility Notice (Perm)