9907-429 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of,perjurythat.l 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
97 17 B
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 (Seca 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.
(!C) 1 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.
STATE Fifth 467-99.0%, 0120
(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
workev,-'compensation laws of California, and agree that if I should become
sub�'ect 1' )°he worke}''s' compensation p visions offit
ectiom3700 of the Labor
Cede, I Sh9l�lfoi�ilsh comply with those bDate: l I APPlicarit l
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
thea ove-mentioned pro ;e n'for inspection purposes. ' C
10 Signature (Owner/Agent) Date
BU ILDINGIP.ERMITT- PERMITl1
lid U7a29.; ..
TRACT
DATE VALUATION LOT , .--
'� (a; !iJt3.3G.�3 y�l 7..5}53
JOB SITt
APN
ADDRESS 79-322Nt UIC#VODRIVE ,
604-071-611
OWNER
CONTRACTOR / DESIGNER / ENGINEER
C'LIPHAN`t' AND:WLLI 1MS AS.S0C_; DJCJ
OLIPHAW MJTD WfLLIA MS ASSOC., INC.
77"900 AVFMME, OF T.-9 STAT8S
77-09130 AVENUE OF 7'AE STATES
PALM DESERT CA 92211
P_AL,Pr1. DESERT C;lA. .9 22) 11
(760)345.2Q6. CBL# 5203
USE OF PERMIT
tiltti(c31,1~ h.Alt�iil..''l f�A4/1:t,1.tt�3C1
'
5FD - LOT 51+. PLAN 3B, PM, 41T DOES NOT lNQ_1U7 'J 'S'LCXK WAf L OR
P001– 730,10 PL tU. 4 CIIECK 1f:F, FOR 2edQX.'1IPIX" 1SWA'NCF, OF SAME PLAN:
t'i1�4CI`CONSITRUCfION F
i?C3RKXJPA.'ITIO INJ.04 W.
(SAllPt VICAi{PORT 611W SF
TE.0 t:`t�°�'�' the t'.`d�;��'"ar�g31`:'1'ION
k;��3, 56A0
��g y1?STIiR��.�_?
y�x �a g FEE
f,CS.Y�.i�'.lIiPY. d.' L' E SUMMARY
CON'TI'R(ICTION FEE 101-OOIi4184111
ft.M CHECK FEE 10140;439-318 $16:1.49
r
NtE;.`IfL�AN1CM. FEE .101-13 . -42,'.-No $�56t,�gl
i-�►
1
31,,FC'TAICPJ. ��" 1tY1-iJi�429-U�ifl $I`�Pl:•13
� � .
PLOn113MGFEE
STRONG m(YrION FEC - X1£9 I01.OW241-000
.
GRAI),'NG FEE 1014)00 -423 -WO IM00
INFRASTRUCTURE ME 225 -OW -44;3-:'442 %3,081.61
�ix ! � �• �
OR C ISE PLAN 101-000-441-345 S25.00
t',�r •.?
ART IN PUBLIC ,PbACM - •'i , Sit; 701- 000-`2 455-M
SA,tji3:TIM LCONS'!T JCTIONAND LAN (CHECK
S4,06V
LESS K&PAW I RES
TOTAL I ERr*M' 1?'kil~..S WE NOW
�t�8,4i1llfi.I93
RECEIPT
DATE
ByY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab GradeReturn
Air
Steel
Combustion Air
Roof Deck
�� ^g
Exhaust Fans
0. K. to WrapZ
,� -
F.A.U.
Framing
to .. .'
Compressor
Insulation
5'9 B
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
/27-7-2 S-
Final
Final
Final
3-11 —0
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
_Electric
Waste Lines /3/ ,
Gas Test
Final
Neater FinalPlumbing
Water Piping
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
12 — r 7 -
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)