0005-193 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provision, 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 TTic �.-10131/2(
Date iSignature of Contractr;�
A
s
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
pArte,rfo �ance of the work for which this permit is issued.
/ ' 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 I,UND Policy No. 969-Sb"Ir-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 00 of the Labor
node, I shall forthwith comply wit those pro Islqo cam""
Date: L Applicant W� �/7 �-� �^
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
Yfor inspection. purposes.
Signature (Owner/Agent) ✓�l,��. �/
- Datel `tAl
PERMIT#
BUILDING PERMIT
DATE VALUATION - LOT )05-193TRACT
14it,9.C� i 0v 25953
JOB SITE
ADDRESS 7.9-349 CALLE• PRO S-PFRO
APN
604-.3.2"15
OWNER
CONTRACTOR / DESIGNER / EN (NEER
OIJPF AW- ANIS WILT IAW ASSOC, WC.
OLW HAN-1' AND WIL.L.LAMS ASSOC., WC.
77.900 AVENUE OF9FZ 3T'ATE9
77-900 AVERN'LlE OF THE STPaTui
PALM DESERT Cly, 92211
P'.ALM DESM �A 92211
(760)345.26-26 C914f 5203
USE OF PERMIT
SWOLE P'ANM DVIETf11T O
STM -LOT 10£ PLAN 3.AJV PERMIT DOES NOT INCLUDE BLOCK WALL OR.
POOL, ALL OTHER jPEWAITS RFFI '•T 75% IiMUCTION TO PLAN C13PdK
FEE FOP, MULTIPLY, ISSUANCE OF SAME PIA14 TRPS, ,
TRACT CONSTRUCTIUH "� Z430,00 SF
POR.CWPA'TIO - 78.00 5F
QAAA.GEWMMORT (SP) I2,$37.60
XSTD"TED COST OF CONS`i UC110N
r
PFR:l M FEZ .4`TiTiltF1VL4Ri. t
C014,9TRUCT!ON IEE 101,1000-418.000 S81140
PLAN CHECK FF2 101-000-4.35-318 $167.99
MECHANICAL FEE 1018000-421-000 $00,40
ELECTRICAL FEE 101.000-120-000 $I48.42
PLUMBING PER 101-000-419•-000 $160;40
STRONG N40TION ME- RE51D 101-000-241-000 $14.86
GRADINQ FEE 101-000-443.000 $20.00
DEVRL.OPP,R IMPACT FE 31,907 00
p9.�r
gn-TMAL CONM. UCTION A:NM FLAN C W CK
$3,289.27
L= PRE -P. NTD M.9
`roTIL
�0 00
1rmw FSC DuE mw
JAN 12 2001
+ . k
,RECEIPT
R E
DATE ) 7
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BY��
tl
�F DA �%
INSPECTOR
V
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 -
Framing
_ _
01Compressor
F.A.U.
Insulation
Fireplace P.L.
J� _
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall',
Exterior Lath
Drywall - Int. Lath
_ _
Final
Final I/O/ZPOOLS
BLOCKWALL AP ROVALS
- 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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral
O.K. for Finish Plaster
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
�Z
Appliances
Final
COMMENTS:
Final d—
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
Utility Notice (Perm) f