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9712-052 (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 a1tt2343 ,�'' . 12131!97 JDate L-" td - "j 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. (,) 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., - S7'.i fE FLINT) N) 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 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. (bate: i J f I'.. (Applicant (4,/ 7 , Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $1.00,000, 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 cofnstruction, and hereby authorize representatives of this City to. enter upon the above-mentioned property for inspection purposes. ignature (Owner/Agent)M?� '+ - 4 Date f 7 PERMIT # BUILDING PERMIT CONTROL #' -9712-02, DATE 1 VALUATION $141,24 4�2 40 LOT r�+� TRACT y , JOB SITEy ADDRESS 41ri `OALE__ RAO c01' R1 APN OWNER CONTRACTOR / DESIGNER / ENGINEER TKE EX +adAN10E-CROUP RoCER.5ta-L-L 1q1:46kQGk.! ASSC►C. F(7 C�: I:333a /8615 N.APL S I�R'f E, L A. QAffiV I'A 9^233 PALM D SER Cil 92255 '4 PALM CA 92255'x.. gt^bESERT (70 1772-0222 L' (p �.aYU? t8,59 USE OF PERMIT GOT 14, PLAN SAl2. PLAN CRECK Fa REDUCED !fid Fo k M LAXOL „ 1 f,SSUANCE ©F SArm t LAN TTypE. 5FD-:1?>r mf,r Doo ROT 1N'. MOCK WALLS OR. POOL, , DEC 10-1997 TRACT CONST RIXT.ION -2,4k) 00 S1:' `PORCH/P.A ii? ahtl rF, *t-v� r�� G3A.11Ae�t�tCA1�:1'Qf1Thf vi— LA Q l4 V �r 0%T1lb XrF1ll COST (cif CONStRUMON 141P44#40 40 PICK SIT FEE SUMMARY . CONS 1'RUCT1014 FEE 101-000-4.18-000 $786.50 PLAN CHECK FEE 101.000-439-318 $16198 Eti1ECHAN1CAL Fes; 101-Ot)0-42.1-rt)�$60.00 EL1 C"i`MAC FEE, .101-000-420-000 PLUMBINO FEE 101 ••0.110-4.19-000 STRONG NI OT1CtN FEE - RESID .101-000-241-000. GRAD;i'NO FM 1014000-/123=000 $20.00 NE R AS'! RUC",IVRE .f"T'A 225-000-441-342 ,';42 . $3136.'.5•.1 r�f2.i' IN k'L�L1C", PI..ACi'i;S - Ri~.;31r 70.1-000>'?SS.00C) ;�1ff:�.l.2 1 • ' +9 S1.UE3-'1VIAL CONSTRUMION AND PLAIq C;. -W,,CK $4,558,16. .. LESS PRE. -P.AID F Lffl,S ;;i; T O'TA1.' PcRl .YT > i EES DUB; NOW S4,55&16 . RECEIPT DATE BY/ DATE FINALED INSPECTOR t INSPECTION RECORD y OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade _ _ Q Return Air Steel Combustion Air Roof Deck - Exhaust Fans O.K to Wrap F.A.U. Framing _/ - Compressor Insulation 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 BLOCKWAI I 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 Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection S - Encapsulation Gas Piping Gas Test g Appliances Final COMMENTS: , e Final Utility Notice (Gas) �r 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) 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. ense # Lic. Class Exp. Date 488234 B 12/31/97 /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 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. VQ I have and will maintain workers'. compensation insurance, as required by ion 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. STATE FUM) 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 wosers' compensation laws of California, and agree that if I should become ect to the workers' compensation provisions of Section 3700 of the Labor Dode, I shall forthwith comply with those provisions. ate: 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 3766 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 certtthat I have read this application and state that the above information is coryect. I agree to comply with all City, and State laws relating to the building c?nstruction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. ' PERMIT# CONTROL# BUILDING PERMIT 9712-052a 2 DATE 0 Al VALUATION $141,248.40 LOT 14 TRACT ADDRESS 43-651 PALERMO COURT AP" JOB 609-080-U13 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 SFD LOT 14, PLAN 5AR. PLAN CHECK FEE REDUCED 75% FOR MULTIPLE ISSUANCE OF SAME PLAN TYPE. SFD - PERMIT DOES NOT INCLUDE BLOCK WALLS OR POOL. TRACT CONSTRUCTION 2,400.00 SF PORCH/PATIO 160.00 SF GARAGE/CARPORT 449.00 SF I ESTIMATED COST OF CONSTRUCTION PERMIT FEE SUMMARY , CONSTRUCTION FEE ' 101-000-418-000 $786.50 PLAN CHECK FEE 101-000439-318 $161.98 MECHANICAL FEE 101-000421-000 $60.00 ELECTRICAL FEE 101-000-420-000 $141.48 PLUMBING FEE 1014000-419-000 $140.75 STRONG MOTION FEE - RESID 1014000-241-000 $14.12 GRADING FEE 1014000-423-000 $20.00 INFRASTRUCTURE FEE 225-000-443-342 $3,130.21 ART IN PUBLIC PLACES - RESIC 701-000-255-000 $103.12 SUB -TOTAL CONSTRUCTION AND PLAN CHECK LESS PRE -PAID FEES TOTAL PERMIT FEES DUE.NOW RECEIPT I DATE I BY I DATE FINALED ]INSPECTOR 141,248.40 $4,558.16 $0.00 $4,558.16 Signature (Owner/Agent) Date