0307-230 (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
Date ^~ v'Signature of Contractor
OWNER -BUILDER DEC ARATION
I hereby affirm under penalty of perjury that I am exempt from t e 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.
(w) 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 REPUBIC II•IDEMNI`P. Policy No. IM71601
(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 fort with comply with�.jho a rovr ions.
Date: ± / Applicant `� �+'�
Warning: Failure to secure WorkePp�ompensatlon�6oe a
vge is unlawful and
shall subject an employer to criminaenalties and 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,prroperty for inspection purposes.
Signature (Owner/Agent) Date �.0
BUILDING PERMIT PERMIT#
DATE VALUATION $165,244.741 LOT 37 TRACT 29323-1
JOB SITE ` — — --- —
ADDRESS 4&-:&11D'7 �`4l ARI KI VAY E8P1,.AN .DEArE-0'
APN
6W380-023
OWNER
CONTRACTOR / DESIGNER / EN (NEER
PONDlE,RO:IA T3OMES T1 DIC
POAlIDER03A I-CO��9 1I nic
400 S. FARRE, JI .. DR SUITE B 103
4.00 S. F'AE2IIML DPS SUITE B 103
PAL1<,tI 8PL731 OS CA 92262
PALM SPRINGS Cly,. 922,62
C703j187'•710 C:`IIA 2346
USE OF PERMIT
SFD - LOT 37, PLAN IAXL. PERMIT DOES NOT 'INCLUDE SL.00K
WALLS, POOL, SPA OR DRPIXWAY APPROACH.'955%REDUCfIOIN TO PLAN
CHFXK F'EE DDE TO MULTI`PL.E ISSUANCE OF SAME PLAX TYPE
TRACT CONSTRUCTION 2,?2&00 SF
PORCHiP.ATIO 323.00 5p
CTARAGPJC"ARPORT 854.00 Sly
ESI TCD COST OF C:ON sC'MIUCTION
CONSTRUCTION MZ 101.000-18.000 $370.40
FLARE CHECK FrIIr 101-000-439-318 Vr22.74
MECHANICAL FEE 101.000-421-000 $92.100
i?,I. WTIUCAJ, FEE 141-000-420-000 $143.06
PLUMBING FEE 101.000.419.000 $167.25
STRONG NOTION Imo?'- - RP -131D 101-000-241-000 $.16.53
ORADING +'E 101-000-423-000 31100
DIrVELOPER IMPACT "A 81,405.00
UUB-TOTAL COlt SYRI,FC'1 ON AND FILA v C°IMM'
x;4,431.07
�--. IMS PR&PALD FMS
$0.00
al R--.
All -
5 2003 G
,RECEIPT
DATE
BYD
E FI� ED
INS CTOR
`1 1 .�
ri 64
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
/ ifl
Ducts
Slab Grade
,/ uQ
Return Air
Steel
ombustion Air
Roof Deck
"' ✓ 9
aunt Fans
O.K. to Wrap
_
F.A.U.
Framing
Compressor
Insulation
Vents /
Fireplace P.L.
_
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'
Drywall - Int. Lath
Final
Final
j uPOOLS
- 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
,pR S7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final _
Utility Notice (Gas)
,/WZ
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
J
Final
Utility Notice (Perm)