0304-284 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
0hapter 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
CA0a34 B � �; _ 06!3012.(
Date(I)—wSignature 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
Syction 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 NAq'lONAi.'(i2ltyt3' }� Policy No. 9PiSS309
(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, land agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply. wltKthose prowsions.
Daie:� a1jY AppIi(ant
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 pro�erty!for inspection purposes. _
Dat -0
S
! " Y 1�r. '" at `'
/Signature (Owner/Agent) /1 �.
d
BUILDING PERMIT PERMT#
DATE VALUATION LOT' 1y_"_2"'TRACT
$121,M3.30 ° 30023
JOB SITE
ADDRESS?1e 15 K K -N
APN
• 764-270-017
OWNER
CONTRACTOR / DESIGNER / EN INEER
SHEA LA Q1;11NTA, LLC
S HOM0
60-311 f.R%0GY PARKWAY
81.260 .AVENUE 62
T. A QUINTA. CA 92253
-119 VVi L CA 92€383
(909)633.8996. MIR 6976
USE OF PERMIT
SINO1:,F: 7?A1Mi LY DWEL12#6
3FD •'IAT 136, 'PLAN 42108. PERMIT DOSS NOT )MCq.UDE BLOCIC
WA.US, P<)Oi, SPA OR Q1dNi WA Y APPROACH
CUSTOM CONSTRUCTION 11331.0019F
PORCHMATTO 214.0097
ClA1dAGIUC3ARPORT f`i.i►0 F
NISI�NI9YED C 0.Vr'OF C01gS1 RUC'1 �0,N
PE[fiF7W, SI:iNAT 1AZZY
CONSTRUCTION TION ME 101.000.418.000 $716.1$
PIAN CHECK FEE 101-000-439-318 $3933.48
MECHANICAL IEEE 101.000-421.000 "3106
P,LEC9'PJc J' I, r, ELI 101-000-420-000 $92.SIt
PLUMBING ISLE 1.01400-0-419-000 V IC,*
STR040'MOTION FEE- RESSlis 301-000-2AI-000 $12.13
ORADINCi Mit 101.000.423.000 415.09
'
=VEIA)PER IMPACT FFX, �51�90S.C1
S'UB-TOTAL C;0X=UCn.0 3' PJAN' Cii.T CK
14,016.&4
LESIP IRE -PAID kT:ES
$0.041
e
.
CYI'A.X. `P7 CdI1 Ek ]?' .A DUE l' OMI
,C11�,£S4
LAII 2 8'2003
CITY OF LA QUINTA
FINANCE DEPT. •"�',
RECEIPT
DATE '"
By
DATE
INSP
INSPECTION RECORD
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
A
Underground Ducts
Forms & FootingsDucts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
- �, _
Exhaust Fans
O.K. to Wrap
46 S
F.A.U.
Framing
-
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
d
Final
Finalvlloaz4zPOOLS-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 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 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)
COMMENTS:
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my Libense 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 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
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:
Carver NATIONAL UNION F: Policy No. 7085309
(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 1 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 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 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 LOT 0304-284 TRACT
$121,343.30 186 30023
JOB SITE O' , 6 Z L
APN
ADDRESS ,PRISM DRIVE
764270-017
OWNER
CONTRACTOR / DESIGNER / EN (NEER
SHEA LA QUWTA, LLC
SHEA HOMES
60-311 TRILOGY PARKWAY
81-260 AVENUE 62
LAQUINTA CA 92253
THERMAL, CA 92883
(909)833-8996 CBL# 6876
USE OF PERMIT
SINGLE FAMILY DWELLING
SFD - LOT 186, PLAN 4210B. PERMIT DOES NOT INCLUDE BLOCK
WALLS, P0014 SPA OR DRIVEWAY APPROACH
CUSTOM CONSTRUCTION 1,381.00 SF
PORCH/PATIO 214.00 SF
GARAGE/CARPORT 537.00 SF
ESTIlAATED COST OF CONSTRUCTION
121,343.30
PERMIT FEE SUh04ARY
CONSTRUCTION FEE 101.000-418-000 $716.30
PLAN CHECK FEE 101-000-439-318 $583.48
MECHANICAL FEE 101-000-421.000 575.00
ELECTRICAL FEE 101-000-420-000 $92.98
PLUMBING FEE 101-000-419-000 $116.75
STRONO MOTION FEE - RESID 101-000-241-000 $12.13
GRADING FEE 101.000-423-000 115.00
DEVELOPER IMPACT FEE $2,405.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,016.84
I.E98 PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$4,016.84
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR