0003-206 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
"hapte} 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 ]VIM
Date ��' /1/2 •3 Signature of Contractor'' y*' �� •' -
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.
(E),-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 STA T E MD Policy No. 467-99-00611120
(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: „ /
:fes , /.• •1 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 inspectionpurposes.
Signature (Owner/Agent)`,::.., ! "Date �' / / •,
:BUILDING PERMIT PERMITk
DATE j { 4� fvALUATION LOT TRACT
51.04,757.80 13 25953
JOB SITE
APN
ADDRESS 4"1() CALEX SANTA 13A"ARA604-381-(W
OWNER
CONTRACTOR / DESIGNER / EN INEER
OLIPMAN"T AkM W LLIAW ASSOC., INC.
OT.] PklWr A14D W1:L.I LWO ASSOC., IN,
77-900 AVFI;M OP UM SMITIS
'7'7.900 AVIN(71:. OF THE STAM
PALM D ES`kRf CA 92211
PALM DESM CA 92211
(760)345-262,6 mu 3203
USE OF PERMIT
9WGT.Z FAWMY VWqLWG1
SYD- LOT 13 PLAN IA - P,EIa"IaIIT DOLS NOT INCLUDE BLOCKWALL S OR ;
POOU 75% PLAN CHF,CK FEE REDUCTION FOR MUL T IPLE WSUANCE FOR
SAME PLA14 TYPE,
TRACT CON3,TRUCTIOAI 1, 19.13G SF .
PORCH/PATIO 59,00 SP
0A.g1AWCARPORT 496.00 SF
ESiM8').'ED CaW, OT+ C01qMVCT101q
104,7 57.00
PERIMT FEESLUMARY
CONSTRUCTION FTSE 101-000.415-000 $657.00
PLAN CHECK FEE 101-000-439-318 $140.19
a,
MECH A141CAL ME 101.000-421-000 $47.00
ELECTRICAL, VEE 101-000-420-000
PLUM81140 r+T E 101.000-419-000 $158.75
STRONIO MOTIOW FEE - i` ID 101.000.241.000 $18.49
+. .
�'```
ORADtNO "M 101.000-42.000 $201.00
;; • �„4
DEVELOPER I1VIP.AC'T F1:E $1,90.00
JUIN-TOTAL L0M',i UCT'i0M AND PUM CHECK
$3,068.60
USS PRE-PAIIfl�.3
MOO
TO W. PERART F S DULP NOW
RECEIPT
DATE
BY"- ,,, t
DATE FINALED
INSPECTOR
�Q e/,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_ f�
Underground Ducts
Ducts
Ducts
Slab Grade
Return Air
Steel
Roof Deck
?
Combustion Air
Exhaust Fans
O.K. to Wrap
(o r �F-30—
F.A.U.
Framing
16
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
t Gl7
Drywall - Int. Lath
I1�-13
Final
_
��� 0 fj _Cd"zz,
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 APPROVAL
Gas Test
Electric Final
Waste Lines
_ t —
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
—3O
Pool Cover
Sewer Connection
18 3p
Encapsulation
Gas Piping
Gas Test
/ I
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) ?�.O
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 O r
Final Cfl
Utility Notice (Perm)
1 '
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