0301-191 (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
606 486 .1.3
Date y 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:
Carrier OTATE, MD Policy No. 046001164.1.2003
(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:7• • /• - 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 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, indemni
& hold harmless the City of La Quinta, its officers, agents and employeeD
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information i
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upo
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) - - / Date
'IcIWO
BUILDING PERMIT PERMIT#0301-191
DATE VALUATION a67nT'tlf:,6�iY LOT 54 TRACTJOB
I i
_
SITE
ADDRESS 7.9-M PARKW.G��ai.F.�'.��rtARADI..13OU
APN 609-360.0"
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LAQUINTADCiVE2, 350
5005 Ga'UE 3AN RAPILM3, "SM 3'j.
5005 CAT. LF SAN RPJ?HfiE1,, STR !31
PARI S?X' L943S CA 92264
PA:t M VT1.iNGNS CA
uL92y�264. 867
USE OF PERMIT
� , 032- FAMMY DWMJ_ It3
S1F,D - f..UT !4, P1e,"LN 3Y8. PERMIT I T DOS NCYF INCd.txi)E J9.10c ,
MALTA P004 SPA OR i, RIVKhl.AY APPROACH
TRACT CONSTRUCTION 2,34.0,09 SF
PORCH/PATIO 0.00 ate
E611MAITM COQ°r OF CON iRUCTION
1316,:"2A)
PFMTS';M SUMMARY
CUN9TRUCTION YZ?, 101 -0130 -4101 -OW $70.00
PLAN CHECK 79-P 101 -00"39--318 $632.39
MECHANICAL FEE 101.000.421.000 349,00
FLEC" TRX -All. Pili~ 101-000-4.20440 440 $.174.08
PLIUM `FOO rift 101.000-419.0(Xk S13R, ,*
STRONQ MOTION FEE - RESME) I DI -090-241-890 $x3.63
.
GRA USOFFF 101°000.4123-iM 315,00
D•R17N IVIWPUR IMPACT h� $Z405.00
EE DEPOSIT I' 101-000-439-318 -$x(30,539
i
,TM -TOTAL ':O MUC7.1eW .AND I -PL N CF]Lc�IC
$414A . 7 S
i X33 PRE-I'ALD ,
4500.011)
.
n�
Lam\ 0
....�
`I'O TAI, FKRIWT I' ES DUE NOW
JAN 1 2003
Q, F LA OUiN iA
Fih:: .�,MCE DEPT.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
— $• O 3 .S. T
Exhaust Fans
O.K to Wrap
S„—'(,
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
BLOCKWALL APPROVALS
POOLS - SPAS
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
0 3 7
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
— $. 0, %T
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
72rmyo C`o /i?aAs/ a uu y b• /Z•a3 &7'
` LICENSED'CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed underprovisions 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
606486 B 11/30/0z
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that.l 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).
O 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 andwill maintain a certificate of consent to self-insuWfor workers'.
compensation, as provided for ,Section 37.00 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 workees' compensation insurance carrier...& poiicy .no. "are:
Carrier . STATEFUND - •Policy No 04L0011641 2003
(This section need not be completed if the permitvaluation 'is for•$100:00 or less).
O ,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: 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 te 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, indemnity
& 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 ofsuch
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
PERMIT #
BUILDING PERMIT
0301-191
DATE VALUATION $136,1342 00 LOT 54 TRACT 29323
JOB SITE
ADDRESS 79-802 PARKWAY ESPLANADE SOUTH
-
AP” 609-380-023
OWNER
CONTRACTOR /DESIGNER / EN (NEER
LA QUINTADUNES, 350
CORNERSTONE DEVELOPERS, INC.
5005 CALLE SAN RAPHAEL, SIE. B1
5005 CALLE SAN RAPHAEL, SIE. BI
PALM SPRINGS CA 92264
PALM SPRINGS CA 92264
(760)325-4289 CBL# 6867
USE OF PERMIT
SINGLE FAMILY DWELIJNG
,.
SFD'. LOT 54, PLAN 2YB. PERMIT'DOES NOT INCLUDE BLOCK
WALLS; POOL, SPA OR DRIVEWAY APPROACH
TRACT CONSTRUCTION = $349.00 SF
PQRCH/PATIO 45.00 SF'
GARAGE/CARPORT 418.00 SF,
•
;ES'I71l�ATED COST OF .CONSTRUCnON
136,342.00
PTRAd1T<FEE SUMMARY
CONSTRUCTION `FEE 101.0100.418-0001 $749.00
PLAN CHECK FL$ 101'=000^439-3'18 ' $63229
MECHANICAL FEE 101.000.421.000 $47.00
ELECTRICAL FEE 101-000-420-000 $124.08
PLUMBING FEE° 101.000-4.19.000 x$158.75
F s.
STRONG MOTION FEE • RESID 1.01-000-241-000 .$13.63
GRADING FEE •101-000=423.-000
DEVELOPER IMPACT FEE $2,405.00
FEE DEPOSIT 101.000-439.318 $300;00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,1.64.75
LESS PRE -PAID FEES
-$500.00
TOTAL PERMIT FEES DUE NOW
x,664.75
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR