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0003-249 (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 # 5 S LLic. Class Exp., Date6971 i 7 B� � � i �. /3 l �� t Date ' ,t. t - � Signature of Contractor'? 'e� '� :f 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 4wnef 4f the PrQperty, 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: O I have and will maintain a -certificate of consent to self -insure for workers'r compensation, as provided for by Section 3700 of the Labor Code, for .the performance of the work for which this permit is issued. ( r l.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 FUND 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 3700 of the Labor Code, I shall forthwith comply with those provisions. i ,-- ` Date: • j 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 foewhose 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) . ,/, j f - `- -'� l Date PERMIT BUILDING PERMIT DATE/- VALUATION' LOT CSE 3 -249 TRACT t $1Sli�'�56AO 2ti95: JOB SITE.✓ APN ADDRESS 79--' C�a6AR.'9 F[�ae.r.�l�iree;.a604-382-.0137 OWNER CONTRACTOR/DESIGNER/ENGINEER ©LIPHANTAAT WILL&WIS ASSOC., WC: OLIPH€►NT AND WIUJA MS ASSOC., INC. 77.900 AVk ME- OF TBE 3TATE" 77-900 AVF NUE OF TRV, STABS PALM D&SE, RT CA 92219 PALM I3F FRT CA 92211 (760)345.2626. CBlJt 5203 - ' USE OF PERMIT 8.1filUL,9RAM1LY f)W11:iiAAN( SFD- LOT 123 PLAN 3R.0 - PERMIT DOES NOT INCLUDE BL.00KWALL.S OR POOL. 75% PLAN CHECK FEE RRDUCTION FOR MULTIPLE NUANCE' FOR SAME PLAN TYPE. TRACT CONSTRUCTION 21292.00 8F PORCWfPATJO 120.00 SP GARAGE/CARPORT 638,00 SF 1 gr![KA.T" COST 01r, CONSTRUCTION r. , 138,W6.40 CONSTRUCTION FEE 101-000-418-000 rm,00 — - PLAN CHFCK FEE 101-000-439-318 $162.86 MECHANICAL PER 1011-000.421-000 $66.50 ELECTRICAL FEE 101-000-420-00.0 $150.43 ''� '-�t , PLUMBING r. Ex 101-000419-000 $169,90 STRONG MOTION FER. - RESID 101-000-241-000 $13.86 C11tADDI i FER 101-000-423-000 820.00 DLVE;LOPER IMPACT FEL $1,407.00 SUB- fAl.. COW [RUCTIOW AND PJ.Al,3' CHRECIC $3,266.20 7: F33 PRE -PAID FM $0.00 TOTAL Ph-00—If ITEES D LTE .T*#'OW -$3,26610 RECEIPT DATE BY DATE FINALED INSPECTOR � � �i- INSPECTION RECORD OPERATION DATE I INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel LZ Combustion Air Roof Deck Itp� _ Exhaust Fans O.K. to Wrap .Z p 15 F.A.U. Framing y Compressor Insulation h� Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath -� gas Drywall - Int. Lath Final Final 01 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 3 Pool Cover Sewer Connection 3 (o Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) 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: I el h=JPtkoApmdLWW, wbich are dedped' ymwM=X185 bmi mmgaWgvnth CerainTodr MWMIA eau h am not jum tDbe Owtod Fiberglass is zoic SH&dwref on pvmamz.* , I= t1wr effeed4was ager time. it Has mt bemm tested . L maisummur va it ! as mag C4 �Iak T�-T-f -. . z --.. 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