0003-246 (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
Profes,aionals Code, and my License. is in full force, and effect.
•License# Lic. Class Exp. Date
697117
Date Signature of Contractor
J
OWNER -BUILDER DECLARATION.
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the'following reason:
( ) 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is hot 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.
(1), -,['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 TATE 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 Sectionw3700 of the Labor
Code, I shall forthwith comply with�those.provisions:='Xi° ;
Date: .rbt' 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 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) - r'// �- Date
BUILDING PERMIT PERMT#
W
DAT(P/a VALUATION LOT
TRACT
5953
JOB SITE APN
ADDRESS 79411 CA:i..i.E PALM L."�� v 604-M24)34
OWNER CONTRACTOR / DESIGNER / ENGINEER
0LWHW_r,WD Wil -1"B ASSOC., INC. OLIPH NT AWD WIfZAAMS ASSOC., DJC.
77.900 AVON fE OF iii: STAM 77.900 AVMM- 4F'TkM 3SkT��g
P I:l SERT CA. 92211 PALM V SM CA 92211
(760)345-2626 aku 5203
USE OF PERMIT
MOLE FAIWI Y T'i` .,:I.WA3'
SFd,i LOT '14 FLAW 3A PERMIT DOUS NOT INCLUDE 13LOCKWALLS OR.
POOL 11SIX PLAN CHECK FEE REDUCTION FOR MULTIPLN ISSUANCE FOR
SAME PLAN 'TYPE:
T R.AC!T CONST.RUCTIO14 1292.00 3F
PORCH/PATIO
120.00 SF
0ARA0EMAI PORT
638,00 SF
1+ S"i ATEM COST OF C(JN'1 YRUC11Ai4
"
�I �, 6,40
P fl�`[llii'1' 1~ EE 9EIiVIMARYCONSTRUCTION
FEE
101-000-41 o-000
PLAN N CHECK FEE
101-000-439-318
$162.86
MECHANICAL FEE
101-000-421.000
$66'30.
EUCTRIC,°AL FEE
101-000-420-000
$130.48
PLUMBING
101-000-419.000
$169,50
STRDNO MOTION FEE - RELID
101-000-241-000
$13.86
ORADINO FEN
101 -000.423.0001
-
DEVELOPER IMPACT FEE
$1,407.00
OCTA -TOTAL. CObiMCTC'f T.CTN ANIS PLW CFMC K. $3,266.20
IMS :1 RU- PAID IZE 410.00
RECEIPT I DATE
TOTAL. FERMI' ITEENDUE NOW I $3,2665.20
DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
(�
Ducts
Slab Grade
LReturn
Air
Steel
Combustion Air
Roof Deck
p 1��
Exhaust Fans
CKto Wrap
-O
F.A.U.
Framing
'L
Compressor
Insulation
Z
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
3 �\
Appliances
Final
Final ly
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 \ Cp
Utility Notice (Perm)
COMMENTS:
02/092001 06:35 O.J. INSULATION AZUSA + 917603455501
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