0207-067 (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 rrrr
t�.�L rs�a � �TQ . .3 E
f
Date I"1.1" d 2-- 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:.
Carrier Q'Q'ATE I? MID Policy No. (A*01-OD1019
(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 those provisions.
Date:' " "° ju%_ Applicant =i;t4 � Q
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the'building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
'Signature (Owner/Agent)_77� C..�.... lz�.. e, Date IV -4—r. .3 ?
I
BUILDING PERMIT PERMIT#_
DATE < VALUATION + LOT 5 TRACT r.'k
:1-M 29164
JOB SITE'
ADDRESS r� r�csa:� tsri���q.ry hitt wnstY:er''Ci��
APN
OWNER .
CONTRACTOR/DESIINFER
(3:RRL.1V 1j, UX
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NA R....�:'(;'iKD ,F�,t:t1�' �B
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6.A, Q�,�,IJCd h ,K�o "JA - ` 2.25
+965
yC,1.IM-1
i.7.�'44:6,..C�',NT),�9 1 7 6 tq�,.).
I ISE OF PFRMIT
SWGURA14ILY DWHUM0
C) -16 -&-3
[�A
PATIO, F�EF;,-t�TIT Y)ORS NOT IkJt,"i.;i�.D BLOCK WAMAS FRAIt`RU T?t'�t0 I J
K''NO SPA. j F
iF77.-,
CO OM CONSTRUCTION 'ION ;1089.00'Sl{'
CITY®F LAQUINTA
195,00 SF
FINANCEDEPT-
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�j'{�[yg�� y�'�'��ti'E'I'ti�,�
��yy p. �p,�gyr� FRE
P II�..�.i.lYAr F 1 G.1.7.Y.EJYdAN''4Y t ,
:ii�,luT$��IG`Tl(�2t}i*`i«E ]Q1�iiCf�.�u4i;�u�63(t �'I.„�(itS.6iU,
3s!GrZ �r�s;P0f3l'i'
EI.XXTIUCA1.1` X 101 _ 000 47..(i��000 Vila, .
S TROW MOTION RE - R:i..a�� 101 -000-24. l 000 $27.0
03..:000-41S-0 0 $l r.dED
Sfli-TW AL i;OivMRUC`i`i0M AND P AI1i C 4.1:17-.
L�t.,':11151 F�RV-.P.7- ID( 1 ”
4750.0t;)
TOTAL PERMT .� FY's DUN, NOW
M!`l0`�ii .50
1
t
r
RECEIPT .ate. t:
DATE t'
BY �
TE�// ED
I
ECT
F..4
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground uct
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing WELDS
Compressor
Insulationp
3
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
evV/
Jn
��
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 Plbg. Test
Final
Gas Piping
PLUMBING PPROVALS
Gas Test
Waste Lines
��
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out �J/3/ 3
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)
/ o
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring 23i�g
Low Voltage Wiring
_
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
_
r.
Final
Utility Notice (Perm)
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
692234 B HIC 7/31/02
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:
Carrier Policy No.
STATE FUND 044-01-0014319
(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 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 Quihta,• 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 0207-067 TRACT
11/18/02 S278,905,40 P3 PM 29164
JOB SITE
APN
ADDRESS
I
58-457 QUARRY RANCH ROAD
766-060-015
OWNER
CONTRACTOR / DESIGNER / EN INFER
QUARRY RANCH, LLC
C & G CONSTRUCTION
I QUARRY LN
965 NORTH SECOND AVENUE
LA QUINTA CA 92253
UPLAND ' CA 91786
(909)982-9965 CBL# 3539
USE OF PERMIT
SAT0I E. FAR4a-Y DWELLING
p
SFD - 3389 SQ. FT. LIVINQ 628 SQ.FT. OARAOE, 195 SQ.FT.
PATIO. PERMIT DOES NOT INCLUDE BLOCK WALLS, FENCES,
POOL,SPA.
CUSTOM CONSTRUCTION 3,389.00 SF
PORCH/PATIO 195.00 SF
CIARAOE/CARPORT 628.00 SF
ESTIMATED COST OF CONSTRUMON
278,905.40
PERMIT FEE SU lA&4RY
CONSTRUCTION FEE 101-000.418-000 $1,266.00
PLAN CHECK FEE 101-000-439-318 $1,032.42
FEE DEPOSIT 101-000-439.318 4750.00
MECHANICAL FEE 101-000-421-000 $111.00
ELECTRICAL. FEE 101-000-420-000 $213.68
PLUMBINO FEE 101-000-419-000. $184.25
STRONG MOTION FEE - RESID 101.000.241-000 $27.89
CRADINO FEE 101-000-423-000 $15.00
DEVELOPER IMPACT FEE $2,40S.00
ART IN PUBLIC PLACES - RESII 270-000-445-000 $197.26
SUB7TOTAL CONSTRUCTION AND PLAN CHECK
$5,452.50
LESS PRE -PAID FEES
-$750,00
TOTAL PERMIT FEES DUE NOW
$4,702.50
• r
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR