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LICENSEbCON A 'ORDE CL ARAi[Oh
I hereby affirm under penalty of perjur� that I am licensed uoder 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
0413012(�
., Ir
&"05 VM -",)
V Date Signature of Contrac; 161, \
; \ Q , _)_
OWNER -BUILDER DECCARATION
I he�eiby 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
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.
()� 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 Policy No.
I -* AR 12M, 0 N *11 * C %C., 1*6 111' W I 1.1r, el IWO", 0 3
(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
subj�ct to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those,provisio
b6: * J Applicant Z
n7 ��4! 11
Warning: Failure to secure Workers�,_Compensatii n c_
overage 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 abov�-mentioned property for inspection -purposes.
Date -2
S4nature (Owner/Agen(t:��—,V_,/6) k -NA ll�
PERMIT#
BUILDING PERMIT V
14401117-41147
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 74-.,61W4JTRtJS 7 17 e9e� LI)
APN
769-670-036
OWNER
CONTRACTOR/ DESIGNER/ ENGINEER
SHEFFIE1 D I 101MES
3400 cmRAJ. AVENUE- M' -425
3400 C WIRAL ik VE NUF 9IT- 325
CA 9250(1
R1 V ERIS I D U CA 9 2 5, (h 1
(.909)692-5352 01110
USE OF PERMIT
rANINLY DWRTUNG
SIT) - LOT PLAN 3CWPMWTT DOF-q NOT INCLUDE P001, OR BLOCK
WALL
cusi*am coi4siuumoiN
Ibk:_,RC1t1PKFI0 3041W SF
0AI�A00CAPilONT 63701 SF
IM T 1111 A in '3) C M, T 0 F C ONS I IR UT110IN
&.Ap
PERMIT FEE SUMMAkY
CON YFRIX717 ION Fr -J-' 1014MID-418-000
PT,. AN (7T TCK 19-1-- 1101400-430-319 $!)74�97
'%1)X1ItV4I(;1Af1 F 11H VIN !10
mxcmucm, t7as 10 1 -0004204W)C) S197.81
1111AIMMINQ F'EH 101 -WO -419 -WO $1183.4110
,rn?ow, (7)
vNi nir.)N�71--RV.310
(114ADING 11-T-, 101-000-40",000
I NF RASTRUCITURL FER 22 5 - W - 1, 11 -3, 12
AKI'tN IJILRd.IC PLACES - 701-000-255400
FILIT. f)F_Pn31T 47,50 W
c K
A4
LESIS 11RE-1*1111r.) FEE.s
.$7-V).00
TOTillki, PERMITFERS DUE NOW
$8,111.59.34
:4,1wimi
RECEIPT
DATE
I BY
ID
JINSPECTOR
N2
INSPECTION RECORD
OPERATION _F
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR'
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
O.K. to Wrap ?
Framing C
F.A.U.
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath Lei 3
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
I
Underground Plbg. Test
Final I +_
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K for Finish Plaster
ZEELateral
Pool Cover
..-r Connection 1/115 'M
;'as
Encapsulation
�S 5
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
Temp. Use of Power
Final
Utility Notice (Perm) /:2 _Z,
COMMENTS:
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 k Lic. Class Exp. Date
686895 B 04/30/20(
Date 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 the property, am exclusively contracting with licensed
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.
( ) 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 Policy No.
FFZbIONT COMP WN9767563703
(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: Applicant
Warning: Failuie to secure Workers' Compensation coverage is unlawful and
shall subject an tsmployer 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/Agent) Date
BUILDING PERMIT PERMITa
9907-047
DATE �TION
JUL 0 Z 193 $258,121.00 LOT TRACT 2 a$� 90 `7
JOB SITE . . .
APN
ADDRESS 79-000 CITRUS
769-670-036
OWNER
CONTRACTOR/DESIGNER/ENGINEER
SHEFFIELD HOMES
SHEFFIELD HOMES
3400 CENTRAL AVENUE STE 325
3400 CENTRAL AVENUE STE 325
RIVERSIDE CA 92506
RIVERSIDE CA 92506
(909)682-5352 CBL#
USE OF PERMIT
SINGLE FAMILY DWELLING
SFD - LOT 2 PLAN 3CR PERMIT DOES NOT INCLUDE POOL OR BLOCK
WALL
CUSTOM CONSTRUCTION 3,102.00 SF
PORCH/PATIO, 300.00 SF
GARAGEICARPORT 637.00 SF
ESTIMATED COST OF CONSTRUCTION
258,121.00
PERMIT FEE SUMMARY
CONSTRUCTION FEE 101-000-418-000 $1,196.00
PLAN CHECK FEE 101-000-439-318 $974.97
MECHANICAL FEE 101-000-421-000 $98.50
ELECTRICAL FEE 101-000-420-000 $197.81
PLUMBING FEE 101-000-419-000 $183.00
STRONG MOTION FEE - RESID 101-000-241-000 $25.81
GRADING FEE 101-000-423-000 $20.00
INFRASTRUCTURE FEE 225-000-443-342 $5,717.95
ART IN PUBLIC PLACES - RESIE 701-000-255-000 $395.30
FiM DEPOSIT 101-000-439-318 -$750.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$8,809.34
LESS PRE -PAID FEES
-$750.00
TOTAL PERMIT FEES DUE NOW
$8,059.34
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR