0003-251 (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 �. -1'0031121
Date ' '' ';``,c Signature of Contract&,`, -' r 2
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 STATE 1:'UND 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 3_700 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 Quints, 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 PERM T#
DAT -' VALUATION LOT '. TRACT
$127a617.O / S' 23153
JOB SIT
APN
ADDRESS 414-60 CALLE SANTA. DA". .A
604-3M-039
OWNER
CONTRACTOR/DESIGNER/ENGINEER
OLLPHMT AM WKLIAMS ASSOC, L1JC,
OLLPHA14T AND WI ..]AM. S ASSOC., ]I C.
17-900 AVEMM OF THE S'L'ATES
77-900 AVENTIE OF THE STATES
PALM. MERT CA 92211
PALM DFSERT CA 92211
(760)345.2626 CB1,3t 5203
USE OF PERMIT
OWGIZ4 IrAIMY DWMI.NG
SFD- LOT 130 PLAN 0 - PERM1T DOES NOT fNCLUIX BLOCKCW'ALLS OR .
POOL,. 75% PLAN CHECK 113E REDUCTION FOR MULTIPLE ISSUANCE FOR.
SAME PLAN TYPE.
TRACT CONSTRUCTION 2.088,00 SF
POIRCWPATIO 70.00 SF
OARAOEICARPORT 679.00 SF
Esn mm2 COsT O%+ icom'T'Riva.fdom
127,617.80
PERMIT FEE 91JAGAARY .
CONSTRUCTION FEE 101-000-418-000 X7.50
PLAN CHECK 101-000-439-318 $153.65
, _71
MECHANICAL FFA 101-000-121-000 $60.00
ELECTRICAL FEE 101-000-420-000 $135.16
ti
PLUMBING FEE 101-000.419.000' 81;14,00
STRONG MOTION FEE RESID 101-000-%41-000 $12.76
GRADING FBI: 101-000-4423-000 $20.00
DEVELOPER IMPACT FEE $1,907.00
SUB -TOTAL CONMR'UG'110M AND PLAN C1E"K
$3,180.07
LESS PRE -PAID F1 S
$0, 00
TOTAL :P'E10M MS DUE NOW
$.i,180:U7
RECEIPT
DATE
BY 77E
FINALED ]INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs ;
Underground Ducts
Forms & Footings I
Ducts
Slab Grade !
Return Air
Steel
Combustion Air
Roof Deck I
Exhaust Fans
O.K to Wrap I2��
p0
F.A.U.
Framing I
Compressor
Insulation i
Vents
Fireplace P.L. I
Grills
Fireplace T.O. 1
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
f'Leo.
Drywall - Int. Lath I
I
I
I
Final 1
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam ?
Approval to Cover
?
Equipment Location
i
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines I
OO
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral I
3t F6�
Pool Cover
Sewer Connection
r Eqt
Encapsulation
Gas Piping
Gas Test
Appliances I
Final
COMMENTS:
Final I 1a2
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service i
Sub Panels
Exterior Receptacles
G.F.I. t
Smoke Detectors
Temp. Use of Power
1
Final
Utility Notice (Perm) 2Z
Certificate of Insulation
Your Home has bee» imted vriih Cmm'radrW m&n Insulation prod% whicb are de*aed
f" ti's safety Mm&r* and tmonwds muff TCW=nemts.
Fherg m is inorg mic'amd thercbm peim catty aoncozowsWde, so it does aur have lobe treated
withfire-refardaat doemdeats tit wt�l litseiy lase thou effess gnma time, it tms amtloeen treated
with chemicals brat can opr�ade or metal. '� agt abaotb mois�ie nor �l it
settle avec time as may cow in mt[aa mwm.,"
'ibis also cerlifies'that Ce:tainTeed Fii�ea Crtass i,�lat�oa has t>e� naIIp ir>�Iled in tfios liome
to pravide *fioitow ftiherrmel pesfa .
dab Name: Smwisa Tract: Plate. 4 =. Phase: 4
Lot Wa:130 Job Address: 44465 Cafle Santa Barbcay La Q M& CA
CAfft Area: R-33 Unfaeed Ck r'aSC. Ceiliaw
'With Ling Abope
tm dor Wans: Exterior Walls: R -I3 Unfaoed
Ferty.WalEt: With 1&ft A�bave
CZ yrs) Kaes Watls-
Sm0J1AUU410 r Co., lac -
ver. anos c a466M
S%Med—
ContAft Ortiz Secremy Bawer —oma R Sc Jenkins, !°resident—or—
Lou Mem1k Director of Opilatiow Officer
1
R mum adstane to heat Mw. 'The hig% the R vahM the greater the insutatwg P0WM
A* )mw {milder for the fact sheet on R vats Keep ibi=s caaficste with yuor other
vA ned papem if you ever sell this home; this cerd.ficaa shmtld be passed on to the bum.