0005-175 (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
697117 ' B BIC 10/31/7.(
Date 01/0! Signature of Contracto, 4-14 d Y •^'
.
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 orouerty. am exclusively r.,ontmr.tin0 with IIr9nger.!
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.
have and will .maintain workers' compensation insurance, as required by
S ction 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. 4617.99-0000130
(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 tho a pr visions:,.;. -
.Date: J /� Applican '�► -••
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety 4A,
for a permit subject to the conditions and restrictions set forth on his 1$
application.
1. Each person upon whose behalf this application is made & each person at f
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) Date1h
r
BUILDING PERMIT PERMIT#
130'3-! i5
DATE VALUATION LOT BRACT
,
S134A'8.80 25 i. 25953
JOB SITE
ADDRESS 79-326 CALLF 1PALUrrO
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
OL11)HAM'A1M ;1AW:ASSOC'., 04C,
07; PHANN'Z AND VAUIAMS ASSOC., WC,
77.9001 AlfflI (T1 OF .MTE SZATM
77 -900 AVE -NUB' OI' *Y—R.E :TAMS.
PALM 1 WEXf CA 92211
PALM DESERT s CA 92211
.(760)345-26216 f.'M4 5203
USE OF PERMIT
ffigaLk:17AMLY `.f:iiWJa_1MG
• a 3
SND -LOT 25 FLAN 2C],"° ;?P`•WIT DOES NOT INCLUDE BLOCK*ALL
OR POOL, ALL OTHER PERM -ITS REFI,,1vCT 751K REDUCTJ914 TO PL.)t �u
CHZCK 1%Z ICOR, MULTIPLE, ISSU.AIACk OF SAME PLAIN TYPE.. {
TRACT 00149 RUCT10N x,210,00 SF
f
f�
PORCH/PATIL) 150.00 SF
/
OARAGEICARPORT (So t?.`ft70.80
EgrWATED C09r OF C0VS'W(,TCT11DW
Iti�l,6 .IIi
PrL_ttMT FEE 1St WMARY
_
CONSTRUC3I01417-B : 101.000.418.000 $1/62100
PLAN CHECK FE E 101-000-4.:39318 $159.09
MECHANICAL FEE 101.000.421.000 $53.50
laLECTRICALFEE 101-000-420 000 $141.81
PLUMBING F'EF 101-000-419.000 $164.75
S'd RONO MOTION FER RE -531D 101-000441 -OW $13.41
CRADINO FEE $ 101=0061,•4?34000
a3I?V8111AVER. IMPACT FEE
SUB jDAL CUl`iS':CRtlC 100 AND PIM CHEM,
$3,227.61.
LESS PT2E-PAID Fi=3
$0.00
y
AN 1c': 2001 r 'r T rEMT S DUE NOW
.P
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms &Footings
2�
Ducts
Slab Grade
_
Z,� _
Return Air
Steel
Combustion Air
Roof Deck
3-�23
Exhaust Fans
O.K to Wrap
44_I2
F.A.U.
Framing
y �Z
Compressor
Insulation
9
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
�� O
Po6L SPAS
BLOCKWALL APPROVALS
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
21,�
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
Appliances
'
Final
COMMENTS:
Final'/
Utility Notice
-�l
(lp e¢
(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
Utility Notice
�"
(Perm)