9712-051 (SFD)LICENSED CONTRACTOR DECLARATION
I Inereby 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
49923+ ;E { _t 12'31,097
Date, r ~' ' t Signature of Contractor �t
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
said (Sec. 7044, Business & Professionals Code).
( 1 1, as owner of the Drouerty. am exclusively rontrarting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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.
(`t. I have and will maintain workers' compensation. insurance, as required by
Se 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:
Cartier Policy No. .
STATE FIND
6246355-97
(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 pthose provisions.
(Date: l% 1+Y' ( j Applicant ,p i
Warning: Failure to secure Workers' Compensattiion 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 inspection purposes.
/Signature (Owner/Agent) Date .
' t.l
BUILDINGPERMIT': PERMIT#
CONTROL#
DATE VALUATION LOT - TRACT .' 0. 9712-0, "` • 4.
JOB SITE
ADDRESS 4342.1 PALERMO COURT �
APN
��g-(3itQ=0113
OWNER
CONTRACTOR/DESIGNER/ENGINEER
THE, EXCHA;47F 0R(�tm
ROGFR SNELLENBE GE -R &ASSOC.
PO BOY 13335
•8615 N.APLE�S DRRivE, I.A C,�LITIv'CA 92253'
PALLM DESERT CA 922-55
PALM DESERT
CA 922.55
060)7-d'2-0, 2
c1�Lt? . IM. .
USE OF PERMIT
LCT 13, PLAN 318R. PLAN 011EC-K FR RT Dt3CF'D 7-9/0-0R. A1i 114PLE.
RAJ
ISSUANCE OF SANTE• 1?1:AN TYPE, SF'D - PF..RMTT DOES NOT W'Cf. UDE
W
BLOCK WiV LS OR POOL.
MW
T.R.ACr CONSSTWC-11.0N 2,05 00 SF may
P'ORr'HIPt4`C1O 52 41tj ST CITY
0 B
E
LCAU1�
GARAGWC:A:TiPORT =139.00 SF
"
a}
4k 0
3
IESTIC41X-Y ED COST OF CONSTRUCTION l'I:ON
11912SS:56 ;.
PE231411T EEE SUMMARY
CONSTRIXTION Flah"".. 10i. -t>00.41.8-000 sN►9.'t0
PLAN CMECKFEE $1416-98
IMECIVNICAL Fl{k 10.1-000-471-000 $53..50
.
ELECTRICAL FOL 101-000-420-000 �1111.i1�5
PLLIV03ING FEE 10.1-iSM11.19-000 $140.75
STRONG MOTION F.�• - R SID 101-000-24.1-M $1,1.93
GRADING FFE 101-000-423-000 $20.00
- -
tN't7RAS'rP,vc' U`t1.fs F'kE 225-00(1-1143-3412 $2�CsG7, 1
AR` IN PW3L1.0 PLACES - RE3112 701-000.255-0110 W.1.3
'
t i�ax
VB-TMAL CONSTRLK_"f1.0N AND PLAN CHECK
$3,.92
LESS PIE -PAID FEES
$f).0t,
TOTAL PERMIT FEES DITE NOW
$3,926.59
RECEIPT
DATE
BY
DATE FINALED.
IPECTOR
NS
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
- 7_ ,
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 — -
BLOCKWALL APPROVALS
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
/ -
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
r, ELECTRICAL AP ROVALS
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: