0304-318 (SFD)LICENSED CONTRACTOR DECLARATION
11hereb*ffirm under penalty of perjury that•I am licensed under provisions of
Shapter 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
Date�(J 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 3706 of the Labor Code, for the
performance of the work for which this permit is issued.
(y) 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 OTr�a,TE.F'+'t31-11) Policy No. 1BG�Jl:3• h
(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, Ilshall forthwith comply with thos4rovisions.
,Date: 'r',.` 16 Applicant—
Warning:
pplicant 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. / y.
,.Signature (Owner/Agent) ir Date '
PERMIT #
BUILDING PERMIT..
y* .
DATE VALUATION J* HM-�� ,ti. 4('1' . LOT l _ TRACT ; C ; k i
t�4�1 l'r
s
JOB SITE
ADDRESS `- s J�.3Nt g r �J t'
_ 1
APN ;h2. 35 a.,'�,��Jr4
OWNER
CONTRACTOR/DESIGNER/ENGINEER
M,'.`v xxy W 'L'r"^.":°d (,P
E � Z:G
CA 92008
a kk2SAD'CA 9203A'
}� 16404,5868 _ C-BLr�, Kyle,
-
USE OF PERMIT
NVU - LAdT 321 ,F1,fa v: AdJL ?tW_441 f 0L6LF4 �A J'r AJ4L;L. ,*,7C:.1St4,UL:.-S. brdf.Lr ,41
t7Q� Ls SPAOR Di.:VEPArAYly.E1.PPlRtiA{".K Cum
1CUVFO MUM. VVLZ ISSUAli`CE; ZV SAM ,Ha'LAW `t'4 i'a;,
C;Wl fO�111: i"O?,iSTRUMON 2,16k3.GC .Ej)
,
PORCHP"PATIO 5125.00 FW
OMJ:OCARPOR:T ";xw or
ETIMATM) COST OF COMPIMCIMOAN
MUM, FEE slyhw/ .fit
Capt NSl�'RUqq��C"�I�J�App��;2+�? .101-000-418-000 �.1'6��.dSf2
S ki M4 C FICC r 1rF, '1 L1 A •''(i%c�-�a iy •. �' ri (:'7 •7%i
MROHANICA, FEE 101-000.471000 $11.4,41D
G11L£:T1iiCJ" Fxy .101-w"20-000 4133.:1
M10MV1,1140 FFIR �0 �0QIti�l, �ti t`y 1 Y :io75
NvR.owaMo fcw ITT" wtstri 101-000-249-000 12'
ORAI7WO FFR a►�i.�r30()e �"9�t300 E.? ,tKJ
; 1L^VELf PIR If P.AC T FEE
,ART IN PUBUC, IVILAtwF,S iR'a#NEi 1170_11XI7r445-000
J(.M-".t'.(5rtd. COMEMY;.i:U171 °. YN AND PLfir 4 OHM?.
Ll
CITY L;"' QU1NTA.. ,.
f0op
RECEIPT
DACE r
BY 1 Ji
DAT FIN L
INSP TO �.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings 7 o
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
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 (�
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
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:
/ '�' 03
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)
I hereb%l affirm -under penalty of perjury that I am licensed under provisions of
Chapi; :; (commencing with Section 7000) of Division 3 of the Business and
f4ofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
760335 B 3131105
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 br 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&RC. 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 STATE FUND Policy No. 1608301-012
(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, 1 shall forthwith comply with those provisions.
Date: ADDlicant
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/Agent) Date
BUILDING PERMIT FERMI
0
0304-318
DATE VALUATION $221,157.40 LOT 35 TRACT 29147-2
JOB SITE
ADDRESS 57-435 SEAUNOLE DRIVE
APN 762-350-024
OWNER
CONTRACTOR/DESIGNER/ENGINEER
CRV GOLF WEST, LP
?.SHBROOK DEVELOPMENT COMPANY
5141 AVENMA ENCINAS
5140 AVENIDA ENCINAS
CARLSBAD CA 92008
CARLSBAD CA 92005
(760)804.6868 CBL# 3376
USE OF PERMIT
SINGLE. FAMILY DWELLING
SFD - LOT 35 PLAN 2A. PERMIT DOES NOT INCLUDE BLOCK WALLS,
POOL, SPA OR DRIVEWAY APPROACH. 75% REDUCTION TO PLAN CHECK
FEE DUE TO MULTIPLE ISSUANCE OF SAME PLAN -TYPE
aQo i Caves
CUSTOM CONSTRUCTION 2,615.00 SF
PORCHIPATIO 525.00 SF
GARAGE/CARPORT 534.00 SF
ESTIMATED COST OF CONSTRUCTION
221,157.40
PERMIT FEE SUMMARY `
CONSTRUCTION FEE 101-000.418-000 $1,066,50
PLAN CHECK FEE 101-000-439-318 $217.42
MECHANICAL FEE 101.000-421.000 $111.00
ELECTRICAL FEE 101-000-420-000 $135.71
PLUMBING FEE 101.000419-000 $181.75
STRONG MOTION FEE - RESID 101-000-241-000 $22.12
GRADING FEE 101.000-423-000 $15.00
DEVELOPER IMPACT FEE $2,405.00
ART IN PUBLIC PLACES - RESIE 270-000.445-000 $52.89
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,207.39
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$4,207:39
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR