0003-245 (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
697111 B ' � �'� 013114
Ile
Date °`S =j fn_. 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business, & Professjonajs
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 Jor by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( J--I'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 FUNID Policy" No. 4672-09-0000120
(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: ,•r ADDlicant �� .�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal'penalties and civil fines up to $1.00,000, 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)"')?/ `2-
J
BUILDING PERMIT PERMIT#
DATE! VALUATION
.- LOT' +<ia03445 TRACT
25,953 .
JOB SITE � APN
ADDRESS 79-3-05 CALLE. PALMP W4.382 -M
OWNER I CONTRACTOR/DESIGNER/ENGINEER
OLIPHANT AIM WILLWAS ASSOC,, INC.
77-900 AVENUE OF °S7•£, STATFS
PJIVIM D9113 "J' CA. 922,11
USE OF PERMIT
SING, LE F'AMMY'rrjW01 % 40
OLIPHAN`I' fiM Vtf.[1.3,.LAWASSOC., INC,
77-900 AVENT.J'E of TI3L nAm-
PAUA DR ERT CA 92211
(/60)34.5.2626 (BLS 5203
S.i D. LOT 12.1 ALAN BBI: - PERMIT DOES NOT 1NC: uos BLOC:ICUFAI u; .
OR, POOL, 7S% PLAN CHECK FEE REDUCTION FOP, MULTIPLE 13SU.ANCE
FOR SAME FLAN 'TYPE.
TRACT CONST'RUCT'ION 3,210.00 SF
PORCH/PATIO 150.00 SF
OAIEAGE/CARPORT, 643.00 SP
Esmixrn con oy, fv:tym,lRvarioN
134A96SO
CONS 1. RUC T IGN FEE
101-000-418-000
V 762.00
PIAN CHECK FEE
102-000-439318
$154.02
t !
--JI
MECHANICAL FEE
101-0004-21-000
$53.50
..,,
ELLC'I'RiCtA.L FEE
101-000.4.20.000
$147.61
PLUM2 DID FEE
101.000 41.9-000
$164,75
c
STRONG MOTION FEE • MID
101-000-241-100
$13.47
€'i."
C1RADING FEE
101.000.42'1.000
S20.00
i
Hit
I .
DEVELOPER IMPACT FEE
$1,907.00:.-
i
�..� .
SUB -TOTAL. COMYCRUCTIOAP AND PLAN CHECK $3,227>61
LESS PRE -PAID FUS $0.00
TOTAL PERMff FEERS DUE NOW - $3422:7.61
f .
RECEIPT DATE B�Y DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
_
&
Ducts
Slab Grade
(9
Return Air
Steel
Combustion Air
Roof Deck
o
Exhaust Fans
O.K to Wrap
o) CL
F.A.U.
Framing
Insulation
c
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
pO
Final
Final a -
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
O tf1L
Encapsulation
Gas Piping
Gas Test
IS Ofj
Appliances
Final
Final 0)
Utility Notice (Gas) NEE
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)
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