0003-244 (SFD)LICENSED CONTRACTOR DECLARATION
(,hereby affirm under penalty of perjury that I am licensed under provisions of
•+°i✓hapter 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 B 10/3112(
Date a > - Signature of Contracto�7^-
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 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, Buslness & Professlonals
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.
(.,)�I-rave and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, foe the performance of the work for which this
permit is issued. My workers'. compensation insurance carrier & policy no. are:
Cartier STATE FUND 467-99-0000120
No. 46 7.99-0000120
(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 .1 should become
subject to the workers' c6mpensatioif provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. • ,,-T
Date: l - 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 inspectior%rposes.
Signature (OwredAgent),r'%-• ' �' �'� Date
BUILDING PERMIT PERMIT#
//////
DATE I /„ _ VQ�I ATION LOT 000."24'4 TRACT
�(/`�t jj 5138, AO 259.53
JOB SITE
APN
ADDRESS `19-390 CAUE PAJ aWT,Z,
04^'381-01:1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
OlffrHANT ANS W LLL4W ASSOC., )[NC.
OLIPHA'NT AND WILLIAMS ASSOC., INC. .
77.900 AVENUE OF THE STATES
"77-900 AirEI�W OF THE S;!'=
p4L24 DEMT CA. 92211
PA'L.M L'iESIMT CA 92211
(760)345-2626. dws 5203
USE OF PERMIT
ONLIt FAMILY IYWEL,LIl G
SYD- LUT 21 PLAN 3111C - P1:RMIT DOES NOT INCLUDE HLOCICitiIAL1, OR
P00U IS% PLAN CHECK F ER REDUCTION FOR % U 1,TIPLE IS FCR.
SAME PI AN TYPE.
TRACT CONSTRUCTION :1,292,00 SF
PORCHIP,ATIO 120.00 SF
(JARACEfrARPORT 638,00 9F
ES17MATED C.'OS'i OF C014S'IRUCrI014
� � #1343,556.90
PRPdV T fi3tlliD"12Y
CO-4STRUCV014 kE. 101-000-416-000 r7 oo
PLAN CkIECK FLEE 101-000-439-:319
r 7
h9kCilANICALFRE 101-000.421.000 $66.50
'v '
ELECTRICAL VE9 101-000-420-000 $150.4
PLUMBING FEE 101 tl000.419.000 $169.30
STRIONO MOTION FEK - R.E.SID 101-1100-241-000 $1.3.86
�y 7
GRADING FEE 101.00o423-000 $20.00
F9LWL0PEJR, IMPACT ETL $1,907.00
SUB -TOTAL f ON9 RUCTION Ai+TD PI'AM CWCK
$3,266.20
LESS PRE -PAID FEFS
$0,00
TOTAL PST FEES DUE 14 OW
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
k
Underground Ducts
Forms & Footings
AM
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
��L
Exhaust Fans
O.K. to Wrap
Framing
(r)
117p
F.A.U.
Compressor
Insulation
C2 Fd0-
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 a o►
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_so CFC
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
$p
Pool Cover
Sewer Connection
$(
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final L
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
Utility Notice (Perm) �.o
COMMENTS:
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