0005-212 (SFD)LICENSED CONTRACTOR DECLARATION
"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
897117. 131'`11C 0. silt
Date 1% o f Signature of ContractoFs'"o'e�'`l/d��
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 orooerty, am exclusively contrar•,tin0 with licenced
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 consnt 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.
e(( 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. 4b7-9S+-9t3J01?,U
(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 withthose ¢royisio,�^"
Date: 1/1 Gf .Applicant 0' 0—
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. e
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 k
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 informatiowis
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 insp ction p�ur oses
Signature (Owner/Agent) ate
BUILDING PERMIT PERMIT#
OOM- 1 2
DATE VALUATION LOT. TRACT
�i3;. 12.3• 2595;
JOB SITE
ADDRESS i51wi7� CllsL1T�nr,'_r�Wa>>r'C3
APN
604
OWNER
CONTRACTOR / DESIGNER / EN &NEER
O7.IPHAAil AAT13 VAUXAW ASSOC., INC.
011PEikNT AND WILLIAMS LAMS ASSOC., INC.
77 -900 AVE Oki T.t 1E Si AM-
77-900 AvMaUR OF TBE S?`Aa
PALM 1;'il u'LE;,C° CA 92211
PALM T):F -Tip' CA. 92111
.(760)345-2626 CBL4f 5203
USE OF PERMIT
WOLE 1!A7F.y I!t`.la`
SFU -LOT 123 PLAN 38R. PEK-MI T 'bOES NOT rNCLUDX BLOCK WALL OR '-
POOL, ..A.LL OT!HIER PF.,R1 ITSE REFLECT 759'x+ R,FDUCTION TO PLAN
CHEC ftz' F'OR MULT'i.PLE ISSUANCE OF SAM1? PLAN TYPP_
.:TRACT CONSTRUCTION 2,392.QC) $Tt
PORCH/P.AT10 i2om sri
0AR,AOUC'ARPORT (2F) IZ504:30
-
FSTDAATM COST OF CONSrI'l. VC117ON
1:38,558.40
FMUAj'I• bW 3iT.t MARY
CONSTR CTI N FEE 101.000.418.000 5776.60.
PLAN CHECK FEE 101-000-439'-318 $163.96
MECHANICAL FEE 101.000.421.000 1600
LLEC'1."IJCAL F79 101-000-420-000 0-000 $130.48
PLINDINO FEE 101.000.419.000 1;169.SN;.
:; rROM MOTIc�N FEE - P.1�`;ID 101-000.241-000 X1'3.8& i
CIRADINO FEE 101-000-423.000 $20,00
r
DEVI, LOPER IMPACT FEE $1,907.00
Fn' z
� r
l..O3Yo71RUC11.0AND A'1r& Lr&7.1:AOK
$�,266. A.O ,
1.M3 PRE -PATI) —FRES
$0.00
TQ AI: PMM—U:1R`'�'�51�UE N,OWIT
R1 +fyR„ f id 12:200
RECEIPT
DATE, I f
BY fny r'i
DATE FINALED
INSPECTOR
INSPECTION RECORD
r
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
ai zi
Underground Ducts
Forms & Footings
Ducts
Slab Grade
�o
Return Air
Steel
`2p
Combustion Air
Roof Deck
$
Exhaust Fans
O.K. to Wrap
Ito
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
Drywall - Int. Lath
�Q
Final L �� �C,
BLOCKWAL APPROVALS
Final
steel
POOLS -SPAS
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
2 .P
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
14
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final —�
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 1A( LI
Temp. Use of Power f C> -6H
Final
Utility Notice (Perm)
COMMENTS: