0003-207 (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 B ;' 10/31/2(.
Date �.r - 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.
( 4)-'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 STATE FUND Policy No. 467-99-0000120
(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 700 of the Labor
Code, I shall forthwith comply withthose provisions.
Date: ;.. J Applicant''" . i -.:./_,r.,:/ . f -e,___-
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 for inspection purposes.
Date
Signature (Owner/Agent) -� 'f �'' '
�. ,
BUILDING PERMIT. PERMIT #
���
DATEi VALUATION LOT 207 TRACT
j) $148,55.9.00
23953
JOB SITE]
APN
ADDRESS ewsso cyLux SANTA B A
604-381-006
OWNER
CONTRACTOR/DESIGNER/ENGINEER
OUPHAV17 AND WlIIIAMS ASSOC., INC.
OLIPHANT AND WTL.LLWS ASSOC., WC,
77.900 AVE1RM OF THE STATES
77-900 AVMME OF THE STATES
PALMDENIM CA • 92211
PALM DFSMI T
CA 92211
(760)34.5-2626
CBVi 3203
USE OF PERMIT
SWOU FAMILY DVIELU G
SrtD. LOQ' 14 ALAN 3.A - PEMIT DOES NOT MICLUDE 1JI.00ICWAi..T.S OR
POOL 7S% PLAN CHECK FEE REDUCTION FOR MULTIPLE ISSUANCE FOR
SAME PLAN TYPL.
TRACT CONu YRUCTION 2,400.00 SF
PORCI-t/PATIO 73.00 sty
G ARAGEICARPO iT 656.00 8F
RSTYIAXrffiW COST OF CONSTRI CYnON
140X9.00
CONSTRUCTION Fr1I? 101-000-418-000
.:.- t
PLAN CHECK FEE 101-000-439-318
MECFIANICA.t, FEE 101-000-421.000 $60.00
-r? -
ELECTRICAL ME 101-000-428-000 $148.43
PLUMBING] FEE 101.000-419.000 $160.00
STRONO MOTION IF E - RES1D 101-000-241-000 64,86
_ Zi
GRADING FEE 101-000-423.000 120.00
DEVELOPER IMPACT FEE 51,90%00
j
z
gUE-TOTAL CODI13TRIJC1I014 AND PLAN CEiECIC
$3,793.25 k
ISS PRE -PAID FRES
saw R.
TOTAL PMI1211' FI C DILIVE NOW
}
'1
i
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
• $ 00
eDL
—Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
(� (i .Cry
Exhaust Fans
OX to Wrap
F.A.U.
Framing2
Insulation
pl 010 _
p oa
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final _ cC
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
8LIM ('g
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
(2 (30 C f1b
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
ALSP
Appliances
Final
Final
Utility Notice (Gas),
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit�V�
Rough Wiring
Low Voltage Wiring
Factures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) p
COMMENTS:
L�
si
be -skirt sa'nds�-uniried"S.cho"Ol'.Digtrict,.';
47-950 Dune Paltns.Road
Notice: i La Quin'ti, CA 92253'
Do,annent Cannot Be Duplicated 700-7714515' -
CERTIFICATE' OYCOMPLIANCT,.'
Date 10/2/00 API W i 604-381-006
No. 21037. Jurisdiction. La Q*ta
'Owner Na Oliph4nt-!�, Williams,Assoc. Inc.
me Permit #
Ivo 44-1 .180 street d.BarbaiiLog
W"
City -,La Quints,:;Zip 922531,g Study Area
Tract # Lot # S•qua;�',Footage .40
Type of Development New;'-Reside4i4AdditiQn No. of Units
Comments
4'
Sands Unified School, D istrict does not co leci ;fees o garages/carports, At the present time, the Desert I n. ges/carports, covered
patios/walkways;residential,addiiiong under 500 6 ` ;sqb4resfe
et'deia6hid,accessory structures or replacement mobilehomes. It
"has been determin6d theabove-named'ownerPJs6xempt
from p4yj,ng`s�.cho - o�l i6es-at this time due-to'jhe' following reason:
Add.,ofSa. R.A0 New"Cbmtruction
EXEMPTION NOT APPLACMME
This certifies that school facility fees imposed pursuant to Government Code 53q80. in the amount.of
2.05 X 40 o'r$ 82.00 the 'property fisted above and that building
permits and/or Certificates of idccupanqy'fdr this,square age ifootage n this.,propo§ed proje- inay;now be issued
I project
Fees PaidByCASH --Michael 04phant Telephone .-, -.
-Name on the clf&k'
By Dr. Doris Wilson
j
Superihtehdient
r.
,
Fee collected /exempted by EflenPatinb PaymentReceived
C 1qo IMA
h-6ck'
Signature
NOTICE: Pursuant .tAsseinbly Bill 3081 (CHAP,549, STATS. -1996) this. will seA to notifyyou that the 90 -day approval ip.;io.dinw hich,jqu may protest4he fees or other payment iden led
above wi'll begin to run from the,daie.on which'the building or installation permit for this project is ssiuid or,on which they are paid to, the Dikrict(s) 'another public entity authorizedto
collect them on th6'Dist�ct('s)(i')'b6hak',y�6iche4ee is e'aHier',_
t i
Embossed Original- Building Dept./Applicant "C6py-Appiica,,h,,i4,e,c,eipt, Copy -.Accounting
02/092001 08:35 O.J. INSULATION AZUSA 917603455501
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NO. 323 D15
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