0003-241 (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
697117 13 d �10131E2t
Date, !�. u 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
CO yramrs 16 C6fttriict fh(e 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.
have andwill 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. afi`7-9900ffC+llti
(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.
Date: ✓ ' i7 • Applicant �r
4'
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 .condit_ions 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.
I 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 wcirk,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 prope'rfy for inspection purposes.
Signature (Owner/Agent) 'fr r ' -''' `� Date,'/
BUILDING PERMIT PERMIT# I
DAT VALUATION LOT OOOM TRACTF
&134,6E".80
25 95 3
JOB S T
APN
ADDRESS -19-438 CA?LE PAI'..ilW" jT(j3
604-381-010
OWNER
CONTRACTOR/DESIGNER/ENGINEER
OL TPki"`I' AIM WH LIAMS ASSOC., 19C.
OLIPHANT AND WI LTA]M S ASSOC., INC.
77.900 AV IRM OF 1IiB VATES
77-900 AVTtAM OF TEP, STA775
PA7:.14 DESERT CA 92211
PAL DESEWr
CA 92211
(760)345-2626
CBL# 5203
USE OF PERMIT
0TC112 EA.4i, Y DWL71L�.AWO
SFD- LOT lE PLAN PERMIT DOUS NOT INCLUDE SLOCIMALLS OR
PMOL
TRACT CONSTRUCTION 2,210,00 SF
P01ZCF PATIO 150.00 SF
C. ARAGIUCARKIRT 643.00 SF
ES"I`[IM'TED COST OF CON'S'17ZtrCnON
434j698.60
PER1i/Iii' FEE" q�RY
,1
CONSTRUCTION FEE
PLAN C.IMCK° FEE
MECHANICAL FEE 101.000-421-000 $53,30
ELECTRICAL FEE • 101-000-420-000 $147.81
w: {
PLUMOTNO FEE 101-000-419-000 3164.75
STR.ONCI MOTION FEE - RLSID 101-000-241-000
ORADI G FFE 101-000.423.000 $20.00
DEVELOPER. IAIIPACT F&E $1,907.60
f
SUB -TOTAL CONSTR.UG` ON• AND P1. AkT CHECK
IMS PRE -PAID FET,S
$0.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
p
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
Ir 0
F.A.U.
Framing
2 $ jc�
Compressor
Insulation
�2� , vZolo-,
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
2 ( Z
Drywall - Int. Lath'
Z )
Final
Final of
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
3A
Pool Cover
Sewer Connection
gp
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final 2D
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 Z
Final CD
Utility Notice (Perm)
COMMENTS:
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