0005-188 (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
69,7117 B I11C ,✓ 10/3112.(
Date I 147t`t 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).
( ) I, as owner of thepproperty, am exclusively contractinq with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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
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 sTA'TE 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 pr. visio s.
Date: I ZZ 2.101 Applicant —4.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of .the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for. 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
'correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agen r _A V. �l _ 'Date 4�
/
BUILDING PERMIT PERMIT II
I➢1i1ik
DATE VALUATION LOT TRACT w
101 259$
JOB SITE APN
'ADDRESS 79-289 CAIXX T).AT'iW70 :'604-32&010
OWNER CONTRACTOR/DESIGNER/EN INEER
OL -M Wr AND W RIJAM- .421,100.,1 C. f3La)*IA1J`1 AM) WMLTA2bM.S ASSOC,,114 ,
77.900 AVF-N= 01171IM: E A= 77.900 AM1M0F T1- ,-?1`Al2JE3
PALM DESERT CA 92211 PAL11d DRSI"1 Wf CA 92211
(760)345-2626 031:,# 3203
USE OF PERMIT
MY -LOT 101 PLAN 3C I PERMIT 150'E':NOT INCLiI)DE BLOCK: WALL OR
1 OOIA ALL OTHM, PERMITS i"1,EMEC`t= 75% REDUCTION TO PLAN CHECK'
FF3 FOR MULTIPLE I:11SU.ANCE: OF SAME PLAN TYPE,
TRACT 00143TRUdVON 4252,00 81F
POPiMPATIO ;5 . 120.00 SF
c}A1?ACIIwIC RPORT CS1+2. 12,504,80
Fi5'MAIM) cowl OF COMMUC',Cd01V 9.3�io'5�i.r�1
PRIMM VE9 5i7MINRY
CONSTRUCTION FEE 101-000-410-000
PLAN CHECK PEE 241i�C1C®-�1��-: 1>x+ �IG2.I3b
MECHANICAL FEKE 101.000-421.000 $66.50
ELECTRICAL FEU 101-000-420-000
PLUMBDIq FEE 101-000-419-000 $1641St►
�`IZOND MOTION FETE - RESID 101-i3W-241-000 $13.85
ORAWNG FEF 101a000-423-00.0 $20,00
DiVELOPER IMPACT ITE $1,40'1100
ti.
r,
4:k > y -
' M3.1.13 -TOTAL; Ci)WSTIMMOW AND ]PLM CiiWC, $3,266.20
LENS PRI -:-PAW FFM S0100
-TOWIPMATMI-1418M.F. NOW
.� JAN 12 2001 y
U ', q
ClElflr' DATE BY DATE FINALED INSPECTOR
I I �ct 1114.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/21212— /��� Jnderground Ducts
Forms & Footings_
f �- Y
Ducts
Slab Grade
_
Z1s
Return Air
Steel
2
Combustion Air
Roof Deck
o
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_
, ��$/
Compressor
Insulation
�j'jZ
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
POOLS - 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
2� �o C-
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
N _� 1 \ ('
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances _
Final
COMMENTS:
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
Temp. Use of Power
Final
Utility Notice (Perm)