9712-065 (SFD)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
. / , .. . . ..
498234- 12/31197
./Date
igniature.of Contractor�.
I A
OWNER -BUILDER DECLARATION
l.hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
1,*asowner 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 cohstruct• the e 'project (Sec. 7044, Business &. Professionals
Code).
I am exempt 6nder Sediion B&P.C. for this reason
Date .Signdtuf6 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:
Car . rie.r Policy No.
JTATE F= 62635590
(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 work6rs' cornpensatkon'provisions of Se.6tion 3700 -of the Labor
ode I * shall forthwith cbmply'witti those provisions.
11 f, 1 Cr Applicant- ( . -
f6ate:)
Warning: Failbr6 to secure Workers' Compbnsatf)iybn . coverage is unlawful and.
shall subject an employer to criminal penalties a civil -fines up to $106,000,Jn
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and aftorney'p 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 performedunderor pursuant to
any permit issued.as a result of this applicaton agrees to, & shall, indemnify
& hold -harmless the City of La Quinta,-its officers, agentsand employees.
2. Any permit issued as a result of t ' his application becomes ' null and void if
work is not commenced within 180 clays 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 laW,§ relating to the building
construction, and hereby. authorize representatives of'this City to enter upon
thelbove-mentioned property -for inspection purposes.
ySignature (Owner/Ag6nt) Daie
PERMIT#- CONTROL'#
BUILDING, PERMIT 2465
DATE VALUATION LOT .971 TRACT.
S161,156.90 16
JOB SITE
ADDRESS
78-701 -0 DRIAT
APN
609-090-013
OWNER
CONTRACTOR DESIGNER ENGINEER
ITIE EXCHANGE GROUP, INC~
ROGER SNELLENBERGER & ASSOC.
I VLORENTINA DR.
41-865 ROARDIVALK, SUITE 212
RANCHO MIRAGE CA 9,2270
PALM DESERT CA 92211
(760P`777 '7766 CBLA# 1858 TM
t
USE OF PERMIT
LOT 16, PLAN 6A
SFID - PEMT DOESNOT INCLUDE ]BLOCK WALS OR POOL.
pEc 1.6 1997
®7 UQU
INTA.
TRACT CONSTRUCTION' 2,730.010, ea/IT
PORC"ATIO, W.00, V
GARAGEICARPORT. 06
ESI 4AXED COST Of, CONSUIXTION
161,156-841
FERAnT FEE SUAINIARY
CONSTRUCTION FEE 101-000-418-000
PLA.N CHECK FEE 101-000439-318
NW-CHANICAL. FEE. 10't4)00t42I-W0 $92.00
ELF.CrRIC.0 FEE' 101-000-420-000 $1156.01
,E
PLUM13ING r -V 101-000-41.9-000 $166-00
STRONG'A40TION'M �-'RESID 101-400-241-000 $16.12
GRADING FEE' 101-000-42.3-000� 320:00
INFRASTRUCTURE FEE 225-000-443-3,42 Sll>_509.30
ART IN PUBLIC Pl..ACES - MM' 701-OW255-000 SISZ89
-CK
SIL18-IMT-AL CONSTRUCTIONAND PLAN CHE
$5, .�52
'LESS PR'84'AID FEES
50.00
TOTAL PERAfIT FE E.S.DUE NOW
RECEIPT
DATE
BY!
DATE FINALED
INSPECTOR
--- - __ k - ... -2i- _�4
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
.9
Underground Ducts
Forms & Footings
Ducts
Slab Grade
- a2/- ,
Return Air
Steel
Combustion Air
Roof Deck
-gyp
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
— ' =
Compressor
Insulation
A 6 "VI"VIK
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
4- 77- 9d
Drywall - Int. Lath
.4- -ZZ - xP
ad 2 - ou
Final
Final
1—1 —
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
.Q
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
-/S -
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) to