0005-184 (SFD)4' LICENSED CONTRACTOR DECLARATION a
I her affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3of the Business and
Professionals Code, -and my License is in full force arid effect.
License # Lic. Class Exp. Date
Date •!r. Signature of Contractor e �, ,��-�'' �+
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.
S,,)t_I have and will maintain workers' compensation .insurance, as required by
`9'ection 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.
SIATF MND .467.99-0090120
(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 p ovis ,.--'
Date: ��P Applicant a �Y� , ,
Warning: Failure to secure Workers' Compensation coverage is unlawful andv,
shall subject an employer to criminal penalties and civil fines up to $100,0001 A.,
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application..
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit workis. performed under or pursuant Co ,f
any permit issued as a result of this applicaton agrees to, & shall, Indemnify,
& hold harmless the City of La Quinta; its officers, agents and 'employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation. x
V.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for ins action purposes.
Signature (Owner/Agent ✓, <19M� Date ? /- ,.i<,
BUILDING PERMIT PERMITli
DATE VALUATION LOTTRACT
JOB SITE
APN
ADDRESS
OWNER7�
CONTRACTOR /DESIGNER /ENGIIINEER
(YUPSVAJ3 VJs11P7SdS7t., AC,
>wryN'XN,p71rMp AS SOC INC.
77tr900 AVY_W` +: OF11 q&
71.900 AMUr. OF 11,79 WrINrI414
PA 141 DOW= CA 92211
PA1: A MUM CA 5221
(760)345.2626 CSX 5203
USE OF PERMIT
Sr..t"34,01P S ,Pi.. at+t 4.f I P99R► IT DOZE NOT 1NCLIJ09 i3iOwfCWALL OR
TRACT CONwT31 UCTION DO V
770.00e
PK�3ACA�>p�5dlyYtdd�'ips k7f�.�y�
�y i
�('RY'kv7,4J,Cpyrn4b il.K"W..06�+� �i'l� �'.�y1DVi?.QY
ES,.'I MED C01W € F CON1SUT417MION
227, 3 7.00
.it .iM1ryl{'.F r-V�,.I{ �i i1 .Af• R11 1.940 .i.,1>,AN.i•J.�
G"OMMUC'S`ION PIT, 101 -000.41$-000 & X47."
P,',. w ,m iarm pne i 0ll -Ota®- 5- # $614.60
f"Isc tAwcAl. Fig"; $60,09
101 $133.16
I9.L%iMBYNO FFR 101.000.41 r=Cali? $154,00
SM)NO MOTTL}kl ME - RMTO 101-00-241-000
00.423a0(K) 3211,90
C9kt i3T�d ' i�'Fl 101-000-423-0(K)
o' .i"iFa►J�l.t" PER IMPACT FEE
a
NID` `
�I�iC?"g� ,...%y�.:.I�:��•.A�,1����..,�.� C�i..C..lt.
1�s�5fi4t.�D2
U33 PRF, -PAM FEES
S NJ Ydd E✓�5 �,DtldJll .599dtlI
$3,641.02
-y
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
q
114.1
4't
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS-
MECHANICAL APPROVALS
Set Backs
Forms & Footings
_
_a _
Underground Ducts
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
_
�6r�
��
Exhaust Fans
O.K. to Wrap
Framing
_ _
F.A.U.
Compressor
Insulation
J
Vents
Fireplace P.L.
_3 _��
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - Int. Lath!_
Ei
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�
��[
�J�` ' —
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
/_
Pool Cover
Sewer Connection
(O ��6,
Encapsulation
Gas Piping
Gas Test
_
E
Appliances
( r
. Final .
COMMENTS: 1
j.
Final
- • 4
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
..
Fixtures
Main' Service
SubTane!s
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
_
w " t.
Ce''difica to of Occu pAN
-�
City of La, Quinta.
Building -and, Safety Department ofti
.This Certificate issued pursuant to, the requirements of ,Section 109 .of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 79-408 CALLE SONRISA
Use Classification: , SFD Bldg. Permit No.: 0005-184
Occupancy Group: R 3 Type of. Construction: VN Land Use Zone: RL
Owner of Building: OLIPHANT & WILLIAMS ASSOC. INC Address: 77-900 AVENUE OF THE STARS
City: PALM DESERT, CA 92211
By:- STEVE TRAXEL
Date: 11-08-01
Building Official
POST IN A CONSPICUOUS PLACE