0105-069 (SFD)LICENSED CONTRACTOR DECLARATION
I;:iereby 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 E�xp. Date
Datef'=•a / Signature of Contractor ~ '
OWNER -BUILDER DELARATION
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 Sectin 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.
s05-10.coolV.9
(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, ander agree that if I'should become
subject to the workers' compensation -provisions of Section 3700 of the Labor
Code; I shall forthwith comply wyt#t t ose.,grovision
Date: 4°2 Applicant
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' Labor Code,. interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,'r-•
for A 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 prope rtyr ii
Ffonsp drion purposes. <----,
Signature (Owner/Agentr-11-'-5'" rY '--^'`"" Date
BUILDING PERMIT PERMIT#
DATEi yALUATION LOT-� TRACT
,
Z,_ `ti •''�,!/ :221.157 A 0 ;fie?
JOB SITE p•.
ADDRESS
1 �. WOLF D. 1.1 yy�q E
7,61-140-015
F
OWNER
CONTRACTOR/DESIGNER/EN INEER
A OAROOK 1'DENIR%CiPh 0-1 CIC1MPMN
A,°1 MIROC3K DEVELC3PIW4Ek T C OW.. !.W
(:° 'C: M&D CA 92008
Ca LIK-3�r) CA 92008
CM)804-6868 10B1IM 3376
USE OF PERMIT
i� W(33LE FAWLY !DVJff1riLWQ-
3FXJ 41,01' 38 PLAN 2A - PERMIT' DOES. NOT INCLUDE. EI=3CW.AL1,
P0, OL S. k DMEWAT APPR ACV. "A% Pf,..&X MCK FEE- PPUZID VOR.
MUL'fi'IPI ? I013ANCR OF SAME T'YI NN TYPE,
CUSTOM� IDN � 615.00 SP
nC:43�/3�,`TRUC:
PY.,1W IIPAP?110 3Ft100
M7AUTED COR' OF 00N9JXUCn0.N
22.1,157.40
PER ':' �t-R.Ir STMMARY
CC�2iI1`iRC4C`f1C� P ;L 101.000-438.000 "Wo
Pt..V CHECK we 101000.439-:3119 $1034731
IVIT-KI��>!ANICAL FEE 101-000.421.000 $85,50
OLL-9C TRICA1, MU 1.01-000-420.000 6121.721
PIAIMMO IM -1 101-000-419-000 00-419-000f 9162. So
S'd`RClN0 MOTION I^'E1? « Tl':1:'MD 101-000-241-000 W.W
GRAMO V'5; ;QIm0i1C6- ; 3a0U°J 9X160
01r ILOPER. IMPACT FER
�F
lr"J LESS P 7r?.f1W.RW?1,i
50100
JUN — 5 2001
CITY OF LA OUINTA
BY
DALE FINALECI
t
ra : 00110T,
4 OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings/(o
_Underground
Ducts
Ducts
191
Slab Grade
:ZL/
Return Air
Steel
_
Combustion Air
Roof Deck
9�/
Exhaust Fans
O.K. to Wrap
! Z/
F.A.U.
Framing
Compressor
Insulation
lQ
Vents
Fireplace P.L.
; Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
I Condensate Lines
Party Wall Firewall
Exterior Lath
D 11- Int. Lat
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
Waste Lines
/��
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
�Q�lv�
Encapsulation
Gas Piping
Gas Test
_
Appliances
Final
COMMENTS:
Final
%1
Utility Notice (Gas)
f
ELECTRICAL APPROVALS
s 7�Z��D/ �✓
Temp. Power Pole
Underground Conduit�1�
_
Rough Wiring
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final _
Utility Notice (Perm)
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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
760335 B 03/31/2(
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:
Camer Policy No.
05-10-0001279
(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: 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 Ouinta, 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 PERMIT# .
DATE VALUATION LOT 0105-069 TRACT
$221,157.40 38 29147-2
JOB SITE
APN
ADDRESS 57 495 SEMINOLF. DRIVE
761-140-015
OWNER
CONTRACTOR/DESIGNER/ENGINEER
ASHBROOK DEVELOPMEN T CC) WAN Y
ASIMROOK DEVELOPMENT COMPA14
5140 AVEN1T'>_AENCINAS
5 14 0 AVENIDAENCINAS
CARLSBAD CA 92008
C''ARLSBAD CA 92008
(760)804-6868 CBL11 337C>
USE OF PERMIT
ZI-124 F_AIIALI .V D_\VE.T .L .illi
SFD - 1,01'38 PLA14 2A - PERMIT DOES NOT INCLUDE BLOCKWALL,
POOL OR DRIVEWAY APPROACH. 75% PLAN CHECK F'EE.APPLIEO FOR
MULTIPLE ISSUANCE OF SAME PLAN TYPE.
C:U°iTOM CONSTRUCTION 2,615.00 SF
PORCH/PATIO 525.00 SF
C- iAR.AOEICARPORT (SF) 10,466.40
ES'104NI;r:D COST OF CONSTRUC'11ON
221,157.=
PERNM FEE S'0MMAI2'Y
CONISTRUCT10N FEE 101-000-1118-000 $954.50
PLAN CHECK FEE 101-000-4:19-3111 $193.73
MECHANICAL FEE. 101-000-421-000 $35.50
E1,ECTRICAL, FEE 101-000-420-000 $121.71
PLUMBING FEE 101-000-419-000 $162:50
STRONG MOT101•4 FEE • RESID 101-000-241-000 $19.00
CIRADIN0 FEE 101-000-423.000 $20.00
DEVELOPER IMPACT FEE $1,90?.00
SU. -B -TOTAL CONSTRLI"CTIO4d AND PLPsd CHECK
$3,463.94
LE SS FRE -PAIL ITIES
$0.00
TOTAL PERMIT PEES ITE NOW
$3,463.94
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR