0305-248 (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
640 4 B L_ 06A.012(
Date i_ ; Z Signature of Contractor �f
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).
( ) 1, 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.
( 4 1 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 NATIONAL UNION F: Policy No. 7035:109
(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
subjectlo the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with- t ose provisions.
Dates j3 C 3 j . Applicant
v
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, hib'
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 Stafe laws relating to the building
Construction, and hereby authorize frepresentafives of this City to enter upon
the above-mentioned property for'Inspection pur'poses. t
�Signature�Ow�er/Agen j0 \+� .. r �_ � �'�^ �^ Datet-
BUILDING PERMIT PERMIT#
8
DATE VALUATION LOT TRACT
JOB SITE7'r�s7
APN
ADDRESS ���.;i.a � ' �.�` "''^
764--27th-.017
OWNER
CONTRACTOR / DESIGNER / ENGINEER
A HONW FOR AC17VE ADUL I"d
8113FIA HC 10M
60-311 '1T'cA.f1C' Y PARK WAY
B1-260 AVMM 62
LA fZUI Td'A CA 92253
71WIRMAL. CA 92883
(.909)833-8996 CRL1 6876
USE OF PERMIT
'c3L—Tz FAWPLY DWRUDTG
.SFD - LOT 176 PLAN 6420C PErRMIT DON'S NOT INCLUDE BLOCK
WALLS, P004 SPA OR DRIVKWAY APPROACH. 7S% RRDUCTEON TO PLAIN
CHECK PEI DUE TO MULTIPLE ISSUANCE OF 3"R PLAN TYPE
CUSTOM CONSTWCTION 2,770,00 SF
PORCIiWPATIO 323.00 &N'
0ARAGEICARPORT 615.00 3F
IH:��'. IAII COSI' 01T CONYMUCT10,11
232,132.90
v
.EAL�i!.�'T� K' WYMWARY
CO211rfRUCTION FEE 101.000-418-000 51110 A
PLAN CHECK FEB 131-000-439-316 $223.41
MECHANICAL F'EZ 101-000-421.-0100
ELECTRlCA.L FEE 101-000-420-000 $1421.73
PLUMBING FRE 101.000-410'•000 $172.00
STP,014 MOTION lYEE - RF -41D 101-000-241-000 03.:11
OEC AlDiNG FU 101.000.42.3.000 $15,00
DEVIU.0-PE t IMPACT MrF' $2,407.010
ART IN PUBLIC P'LACGS - RNSIE L70-000.445-000 $81x:
SUB -TOTAL 0014 gYC'11014 AWD PLAW C1W_C_%
LESS PIZ1 -11AID FEES
$0.00
`FOTAL P:FERM.'T YF -1013 INOW
$4,2.2.0
,
I
RECEIPT
DATE `'•BY
DATE FINALED
INSPECTOR
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
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
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 all
Final
Utility Notice (Perm)
COMMENTS:
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
640934 B 06/30/2(
Date 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 isnot 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 &Profes.ssional'a..s ,
Code).
O 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; oftipthe following declarations:
O 1 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-_ fhhe'work for which this permit is issued.
1 have and,.will maintain'workers' com ensation insurance, as required b
Section 3700 of the Labor'Code, for the, performance :of the,work'for which this
permit is issued..Mv °workers' compensation insurance carrier, & policy no. are:
Carrier NATIONAL'UNION F. Policy.No. - 7083309
(This section need not'be completed if the permit valuation'Is;for $100.00 or less).
( .) I,ceitify that,in the performance; of thd'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-worke,rs' compensation provisions of Section 3700 of the'Labor
Code;::l shall forthwith comply with those provisions.
Date: Applicant
Warriing: Failure to secure Workers',:Compensation coverage is unlawful and
shall subject an, -employer to crlminel:penalties and civil fines up to $1.00,000, in
addition to the,cost of'compensation; damages as provided for in Section 3706
Of.the'Labor Code;,interest and attorney'stfees.
IMPORTANT .Application is hereby made tothe 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 reouest and for whose benefit work is,perfdrmed 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) Date
BUILDING PERMIT PERMIT#
DATE VALUATION =32,13290 LOT 1,76 TRACT 30023
JOB SITE
ADDRESS 60-199 PHII.IP COURT
APN270-017
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
SHEA HOMES FOR ACTIVE ADULTS
SHEA HOMES
60-311 TRILOGY PARKWAY
81-260 AVENUE 62
LA QUINTA CA 92253
THERMAL, CA 92883
(909)833-8996 CBL4 6876
USE OF PERMIT
:.MXGLE'FAMILY. DWELL]N
SFD-`LOT:176 P_LAN.6470C' PERMIT DOES NOT INCLUDE BLOCK
WALLS,`POOI., 8PA OR DRIVEWAY APPROACH, 75%aREDUCTION TO PLAN
CHECK' FEE;DUE TO.MOLTIPLE ISSUANCE OF SAME_PL.AN TYPE
CUSTOM CONSTRUCTION 2,770,00 SF
PORCWPATIO 323.00 -.SF
GARAGE/CARPORT 613.00 SF
ESTIl"TED COST: OF CONSTRIICTION.,
232,13290
PERNf=r SUMMARY' .
CONSTRUCTION FEE 101-000-418.000::.. 81,103.00
PLAN CHECK FEES 101=000=439=318 $273.41
MECHANICAL FEE 101.000-421.000 599150
ELECTRICAL; .FEE 101-000-420-000 $142.75
'PLUMBING,FEE 101.000.419=,OQ0 5172.00
STRONOMOTION FEE - RESID 101-000-24.1=00.0. $23.21
.ORADIN,o FEE 101=0.00-423.000_ $1.5.00
DEVELOPER IMPACT FEE $2,407.00
. ART IN PUBLIC PLACES - RESIE�270-000-445.000 580,33
SUB -TOTAL CONSTRUCTION AND PLAN -CHECK
$4,268.20
IESS,"PRE-PAID'FEE I
$0.00
TOTAL PERIVIIT FEES DUE NOW
$4,268.20
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR