9712-053 (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.
Zate
ense # Lic. Class Exp. Date
488234 B 12/31/97
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.
(f) I have and will maintain workers' compensation insurance, as required by
S ction 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:
Cater Policy No.
STATE FUND 626355-97
(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
wojrkers' compensation laws of California, and agree that if I should become
7 bject to the workers' compensation provisions of Section 3700 of the Labor
ode, 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, indemnity
& 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 certity hat I have read this application and state that the above information is
corr5pri agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
7signature
above-mentioned property for inspection purposes.
(Owner/Agent) Date
�ia�
BUILDING PERMIT PERMITp CONTROL#
9712-053
LOT 15 TRACT
DATE VALUATION 5161,156.80
3
i
►2 t� 97 +
ADS43-681 PALERMO COURT
APN 609-080-013
OWNER
CONTRACTOR/.DESIGNER/ENGINEER
THE EXCHANGE GROUP
ROGER SNELLENBERGER & ASSOC.
PO BOX 13335
78615 NAPLES DRIVE, LA QUINTA 92253
PALM DESERT CA .92255
PALM DESERT CA 92255
(760)772-0222 CBL# 1858
USE OF PERMIT
Sm
LOT 15, PLAN 6BR
Sm - PERMIT DOES NOT INCLUDE BLOCK WALLS OR POOL.
TRACT CONSTRUCTION 2,730.00 SF
PORCH/PATIO 90.00 SF
GARAGE/CARPORT 598.00 SF
ESTIMATED COST OF CONSTRUCTION
161,156.80
PERMIT FEE SUMMARY
CONSTRUCTION FEE 1014=418-" 5856.50
PLAN CHECK FEE 10.1-000-439-318 $715.90
N ECHANICAL FEE 101-000-421-000 $92.00
ELECTRICAL FEE 101-000-420-000 $156.01
PLUMBING FEE 101-000-419-000 $166.00
STRONG MOTION FEE - RESID 101-000-241-000 $16.12
GRADING FEE 101-000-423-000 $20.00
INFRASTRUCTURE FEE 225-000-443-342 $3,599.10
ART IN PUBLIC PLACES - RESM 7014)00-255-000 5152.89
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$5,774.52
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
55,774.52
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
_/y_Q
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
- Q
F.A.U.
Framing
�Q�
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
— ZO - ,
Drywall - Int. Lath
4 -2- / - ,
Final
Final
BLOCKWALL AP ROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
-ZZ7
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
-( -
Appliances
Final
Final
Utility Notice (Gas) `
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Factures
Main Service
Sub Panels
Exterior Receptacles
,G.F.I.
jSmoke Detectors
],Temp. Use of Power
Final rz
Utility Notice (Perm) To cAa
COMMENTS:
'