0003-243 (SFD)LICENSED CONTRACTOR DECLARATION
COj I hereby affirm under penalty of perjury that I am licensed "under provisions of
~ ? I Ch��ter 9 !,commencing with Section 7000) of Division 3 of the Business and
W �; -` toss. pals Code, and my License is in full force arid effect.
r, M rn I License # Lic. Class Exp. Date
697117 B '� lOfll2C
Date ' �' j Signature of Confractor "''/Z
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury -that I amexempt 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
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 . 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.
Date: !.. %' , 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)''; Date `f�{ ✓ yti
BUILDING PERMIT PERM T#
DATE . VALUATION LOT ()()03-24'�' TRACT
!� 138,5MA0 2S9.i3
JOB SITE
APN '
ADDRESS .9_406 CAL LE PAI Iftff�TO
' 604•381-012
OWNER
CONTRACTOR DESIGNER / ENGINEER
otuquHr ham W.iL T.Tpms Assoc., iNC.
OIlPEP14T 1a,M WUJIAW ASSOC., IRC. .
71-900 AGUE OF T -m sS'ATI✓S
77.900 AVMRTE ON'T.H-E s1'AT.e
PALM DES? WT Cha. 92211
PALM T)1::s1 X CA 922:11
(760)345-26265 C13LH 5203
USE OF PERMIT
i&%WLE
STPD- LOT20 PLAN 3B - PEMT DO +ES NOT INCLUDE; BiACKWALLS OR
POOL,, 7514o PLAN CHECK FER REDUCTION FOR MULTIPLE? ISSUANCE—FOR
SAME PLA14 'TYPF.
TRACT CONSTRUCTION 4292.00 ;fir
PORCH/PATIO 120.00 SN
OARAWCARPORT' 638.00 SF
ES"n.PA*AT0) COM.' OF COXnRUC,11' 014
�. 138,556,40
FYiMf FEE SU14MARY
Y, ; • _
CONSTRUCTION FF.,E 101.000-418-000 $'1' &OD
". t-)
PLAN CHIC` FEE 101-000-439-318 5163.9b
+ +
MECHANICAL FEE 101-000.4.21-000 SO&%
!r l
ELECTRICAL PLtE 101-000-420-000. $150.49
1'
PLUMBINC1 FEE 101.000-419-000 $169.50
m_1
STRONG MOTION FEE - .RMID 101.000-241-000 $13,36
wr�a
GR.ADINO PER 101-000-423-000 $20.00
DEVELOPER IMPACT FETE
SUB -TOTAL C O T.'FtTX1, J0N AND PLAN CkF.C1:,C
$3,268.20
LESS PRE -PAM IST
$0,00
TY)T&L PM4-Tr FU DUE .NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms &Footings
Slab Grade
nderground Ducts
Ducts .
Return Air
Steel
Combustion Air
Roof Deck
OX to Wrap
(o� (� _
'SE—
Exhaust Fans
F.A.U.
FramingCompressor
Insulation
p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
( q,
Drywall - Int. Lath
l$. CQ - coa
Final
Final 3 �1
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
a
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final o)
Utility Notice (Gas) ZZ
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 'Z
Utility Notice (Perm) (� p
COMMENTS:
02/09/2001 08:35 O.J. INSULATION AZUSA 917603455501
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NO.323 D09