0202-134 (AR)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
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
rcompensation, 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 -i Signature of
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.
(This section need not be completed if the permit valuation is for $100.00 or less).
(�J I certify that in the performance of the work for which this permit is issued,
ITshall 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: ,._ 1 Applicantt= -°..'..""""
Warning: Failure to secure Workers' Compensation coverage is unlawf4l a d
shall subject an employer to criminal penalties and civil fines up to $100,1 n
addition to the cost of compensation, damages as provided for in Sectio
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and e
for a permit subject to the conditions and restrictions set forth n h
application. C
1. Each person upon whose behalf this application is made & each per o t__
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:eml loyees.
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/Age" n ), ✓ -� !/ ! �� Date!,
yBUILDING PERMIT PERMIT#
DATE f VALUATION LOT 10 02-134 TRACT
452.101
JOB SITE - ' i.w" qp APN �f ,rt,n,
ADDRESS 7i+ w �yl�.�. DWY 6CA-1-74-Flt 5
OWNER
CONTRACTOR/DESIGNER/EN (NEER
.L%,TY V, &. VAY.. NIFY' 1-1 VAN MEA
0W9FR F3ULT..D7iiR
8645 SANYf.ADR .
`
LA CL01N.TA CA 922:33
(760)W36-9060 CMU,
USE OF PERMIT
MMMAL ADDIrCl4. N
W,41L.° ROON4 ADDITION (493 S.F.)
TRACT COM'PlIC'Y.10N 493,00 3F
Ef3JP° 1Ax.4iD cos o.>l! coAmmCJmotT
U069M
CCaf4#7'RUC"1'ION 119- 101-000-418.000 9MM
PLA.1d CHECK VEE 101-000-439-318 $307.42
MECHAMC'.AL ME 101.000-214-100 510.50
E1,W,TR,ICA.L, Fill E 1011-000-420-000 '532,26
STRONG iuOTIM 012, 1D 101 -WO -241 -UM
31 dt} F3T 101-00-423-005
®fSA�.
�.R 0 fl L10�2l�]
TKOF IAQUIRTA
------ -. �'�•=J C.Y'E AL. 4:J�S''�'t'Cit,:''1'IOEJ .�1i+3S� I'L.AA1 ���'.C`�Cw
!�, rw+.k.1��5
J: T1s 1 : RE''.•PAILG1 � RE0
$0.00
RECEIPT
DATE/
BY ! "'
_DPgTE FI ALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
-
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
C. - - Z
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lathi��
Drywall - Int. Lath
Final
_
Final o b .t
BLOCKWAL A PROVALS
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 Laires
Heater Final
Water Pips V
Plumbing Final
Plumbing TDtD Out
Equipment Enclosure
Shower Pons
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Conner. -tion
Encapsulation
Gas Piping '
Gas Test
Appliances
Final
Final
Utildy Notice (Gqs)
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 Cam licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
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
WORKERS COMPENSATION DECLARATION
1 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.
(This section need notbe 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' 6hall moYemploy any ,person in,any.:manner`so°as'to:become;'subject to;the
workers'„compensation laws of ;California, and agree that if'l should become .
subjecito..the workers' compensation provisions of Section_ 3700 of the Labor
Code; I shall forthwith:complywith 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 $1 OO OOO' in
addition to.the.cost of.compensation, damages as.providedjo"r in Section -3706
of ihe'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 resultof this applicato'n 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 arid -void if
work. is not °commenced within 186 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 relatingfo 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#
0202-134
DATEVALUATION LOT TRACT
. $26,�69.90 BLIC7
452.01
JOB SITE _
ADDRESS 78-635 SANTTA DRIVE
604-174005
r
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TONY R 8t VALERIE H VAN WATKLE
OWNER BUILDER
78635 SANITA DR.
LAQUINTA CA 92253
(760)836-3060
CBL#
USE OF PERMIT
RESIDENTIAL ADDITION
FAMILY ROOM ADDITION (493 S.F.)
TRACT CONSTRUCTION 493.00 SF
ES EVIATED COST OF CONSTRIImoN
26,76990
PERMIT FEE SUMMARY'
NSTRUCTION FEE 101-!000 41,8-000. $265,00
PLAN CHECK,FEE 16i-000-4oa;aa;..
MECHANICAUFEE,'. 101-000421-000 519:50
ELECTRICAL FEE 101-000_420 000 $32.26.`
STRONGNOTION FEE -. RESID 101=000.241=000 $2.68`
ORADINO'FEE 101-000-423-000 $20.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$541:86
LESS PRE -PAID FEES.
$0.00
TOTAL, PEMM FEES DUE NOW
$541:$6
ao
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR