0305-119 (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
B EIEC. 08 I/V
'DateL4r Signature of Contractor. �� A 4
j�
OWNER -BUILDER DECLARATION
1 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 istissued.
V) 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 RvuwC 113D1iwit Policy No. 1%71601
(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,shall, forthwith comply with those provisions.
Warning: Failure to secure Workers"Compensatioecove'F,age is unlawful and
shall subject an employer to criminal.p�nalties and civil-fines'up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
I 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
Fir 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, indemnity
Mb & 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) 1^✓ Date /•
BUILDING PERMIT PERMIT#
17'�
DATE VALUATION LOT TRACT
37
t; C: ✓16�7rt1�4.TCD
JOB SITE
APN
ADDRESS 4757 PAR 'WAY ESPJAk ADE WFUr
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
PONDFUZOSA HOMM H, DW.
PO:tdU1"t:ROS.A 110NA"M U. INC
6671 OVnM DR11VE
400 S. F.ARAM.L DR =12, B 103'
PI.F.ASANMN C''A
PALM 8PR'1NQ8 CJA 92262
(703)18'1-710 CRIX 2346
USE OF PERMIT
MNC+r.rll IFAMMY DWELLWG
SFD . LOT 3u PLAN IBXR. PLAN DOES NOT INCLUDE BLOCK
W AL" POOL, EPA. 01ez DRIVEWAY APPROACH. ?5% REDUCTION TO PLAN
CHP. X PKE DUE `!'d)11 MULTIPLE ISSUANCE OF SAME PLAIN TYPE
TRACT CONSTRUCTION 2, -ns. Do SF
PORCI. PA470 323.00 SP'
QAP.AE1Ial'C ARPORT . 654.00 31'
EiRTimm cosTor CONisT6iucnow
P'lt':>td= FEE 90lblr;M:,f1 RY
CONSTRUCTION FEE 101.000.41.8.000 =59
PIAN Cr- WK FEF 101-000.139-318 $190.69
,
MECHANICAL FEE 101-000-421.000 $92.00
EL,ECTPJCAI, FEE 101-;000-420.000 $142.05
PLUMBING PER 101.000-4.19.000 ff 167,23
S RONt: MOTION TiL+E • RMID 101-000-241-600 $16.52
t'
GRADING FEE 101.000.423.OW $15,00
DEVELOPER IMPACT FLS
9M-T0TAI. COAN3TRTJC770N' ALIO PI.AM CWA.,1ti
$3,889.02
D a LMS PRE -PAID 1M
Fr 117W .NOW
JUN 0 6 2003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE //
BY �s i
DATI A y//�
INS CTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings ..
Slab Grade
Ducts
Ducts 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 APPROVAL
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping s
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection J
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)