0003-247 (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
Prpfessionals Code, and my License is in full force and effect.
License # Lic. Class Exp.. Date
697117 :t3 A , . 10/31/2(
Date - Signature of Contractors)
,.lr.. �U, ,r�r✓.
r
OWN ER-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 theproperty, am exclusively contracting with licensed
contractors. to construct the prolect.(Sec. 7644, 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.
( ) 1 -have and will maintain workers' compensation insurance, as required by
Sector n 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 STATI? FU14D , 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.
Date: Applicantel'
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, indemnify
& hold. harmless the City of La Quinta, iis'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)
BUILDING PERMIT PERMIT"
j
DAT
� VALWATION LOT ffl(K -247 TRACT
!{134,980 7595
'
JOB SI E) 1 P�
APN
ADDRESS 79--427 Ct1I.: E PAi.1FaiKl.-M
604-382-035
OWNER
CONTRACTOR/DESIGNER/ENGINEER
OLTHANT AF.dDW1LT.,7AM ABSOC., INC.
OLIPHANT AND WILLDW. S ASSOC., INC.
77-900 AV'M OF THE, 3TATES
77-900 A� TER OF TT -?E 19 TATE S
PALM DES 't° CA. 92211
PALM. D ERTT CA 92211
(760)345-262.6 CBIJJ 5203.
USE OF PERMIT
1�lt�li�.15'ft'`(�11d1L.Y`,l:jVykf:l.,l..,�.t�C3
.
SFD- LAT 126 PLAN 2RA • PERMiT DOES NOT INCL UTZ t3LOCK'WALLS •
OR POOL, 73% PLAID CH ,CK FEE RE, DUCTION Ft;. R MUVIPLE ISSUANCE
FOR S.A.ME PLAN TYPE.
TRACT CONSTRUCTION 2,210.00 OF
PORCHIPATTO ISO, 00 SN
C3ARAaFJCARPORT 643.00 8F
'y
EMMA= COST OF CONS112.i1'anon
134,698.80
VERAM 'rRE SUMMARY
f
COt4STRi3CT10N IME 101000-418'•000 $702.00
" 3
PLAN CHECk FEE 101-000-6139-:318' $159.09
MECHANICAL FEK 101000-421.000 $53.50
• �" `r ' � +
ELECTRICAL FEE 101-000-4.20-000 $147.81
PLUMBING ME 101.000-419.000 $164.75
STRONG MOTION PC, F • R.ESI D 101-000-2441-000 $13.47
ORADiNOFEE 101.000423-000 $20.00
�•� ���:--'
DEVELOPER IMPACT FEB $1,907.00
SUBTOTAL COrtS':1�ttrcl'1:ON ANI) FLAW C'RECK
LESS PRE -PAW FRAS
$0, 00
TOTAL PL— WY,, S DUE NOW
S3,227.61
RECEIPT
DATE
BY
1
DATE FINALED
INSPECTOR
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
O
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
p
Drywall - Int. Lath
Z t o0
Final
Final to o�
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
tj
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final R (c
Utility Notice (Gas) H(p o�-�-
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 O a1 G't
Utility Notice (Perm) A -2A
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