0301-192 (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
60&186 B a
Date /_ � Signature of Contractor -
'y r J
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.
Sec�) I have and will maintain workers' compensation insurance, as required by
ion 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 STA'T'E FUND Policy No. IG�jj��f)R1f34!-3iW�
(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: % - Applicant r'
f.
Warning Failure to secure Workers' Compensation coverage is unlawful and
shall, subject an employer to.cnminal 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 purs.U66t 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 i D
work is not commenced within 180 days from date of issuance bf such r
permit, or cessation of work for 180 days will subject permit to cancellation. ,JI
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) / -_..f r; �. `Date ! • �- -
BUILDING PERMIT PERMIT# 4) Z,
DATE VALUATION ��e� (i_W LOT 51 TRACT A f
,.I
^
JOB SITE
ADDRESS in)r1%?AY �,Ee4.1�L�A.
APN i4Q.�';i;4/!^ISa.3
OWNER
CONTRACTOR / DESIGNER / EN (NEER v'
'
1-kQU7.3 TAi71.MM, +SQ
DEV0,10PERI B, INC, J
5005 CAL]: , SAN I�6LF']HAIL . M BI
5005 C LLE PA4 WHAEL, X41
PAIA-4 SPRINGS CA 42264
11AL M SPR:ll4'GS CA 92264
(760)325-4289 C'SIR 6867
USE OF PERMIT
SWGI.H FAXMY Z. "WEL.I,;fh3'Ci
•T
. . LOT 53, PLA1114 sl'C g- PIMIdiIT DOESINCLUDE BLOCK
UI:ALL.,a.I N)01, SPCA. OR DMEWA.Y APPROACH
TR .AC T t:UNSTRUCTION 2376.00 SF
hOF CHIPATIIJ 45. Do SP,
0; P-4,0EICAR.POR.T 44100 wF
vb" r',ll um cot" or, Comn?.vc'n4?i'r
138,37�W'30 "
CONSTRUCTION FEE 101.000435•000 MOD
P3..AN CHECK 3ri3F. 1101-00"39-318 045.97
M.ECRA14iCAk, FRE 101 -COO -421-000 MIMI
,
VL EC:S`IiJCAL. FEE 101-000-420-000
PI.,UM OINO IM, 101.000-419.000 S M.00
STRONG M0710N ,€ E - RZSID 101.000-241-000 $13.94
OR.AIJi"I• O FEF 101-040-423.000 SK00
zaEVZLOVER 1IMPA .:T IME W03,00
,
IRE D9POSIT 101-000.439-318 _$500.(i4
ti
r C'C3',6^!'0 A1_ COAdWRL[tr1'TOblA D i0T,AAa 01EICK
4,219.9"j'''
T.1W":1 FRE -PAID x;0.2
-$500,001,
s
TOTAL 1;'t+-FMIe'MENDYENOW
ff203 �'
Oq,i}Ft i!a'
CITY
FIPIANCE DEPT.
RECEIPT
DATE ;
BY
DATE FINALED
INSPECTOR "
B.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
`
Ducts
Slab Grade i
Return Air
Steel
Combustion Air
Roof Deck
,2 - / 8 • 9 3 6-5. 5 T•
Exhaust Fans
O.K. to Wrap
$-7
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 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
8. p g7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
ie np C`a iW4 6/ e,Vr-y 6 - iz•o3 s>
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring '
Low Voftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) . p S
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
606486 B 11 /3 0/0Z
Date 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:
( ) 1, 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 ":thii;7 project (Sec. 7044, Business & Professionals
Code). t
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 4ollowing declarations:
O' I have and will maintain;a certificate of consent to self -insure for workers'.
compensation, as`'provided•Jor by Section'3700, of -the Lat or Code, for the
performance of:the work.for.,which this,permit is issued.''
( ) I have"and will maintain workers'compensation insgrance„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 STATE FUND . ” - ,' F Policy No. 0460011641-2003•
(Thissection need not be;comp leted 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 worker,`s' compensation provisions of Section 3700 of the Labor
Code, 1 shall�fogwith comply with those provisions.
Date: Applicant
Warning Failure to.secure Workers' Compensation coverage is unlawful and
shall subject an employiI00 criminal penaltiesrand 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, 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 property for inspection purposes.
Signature (Owner/Agent) Date
PERMIT £/
BUILDING PERMIT
0301-192
DATE VALUATION $138,376M LOT 55 TRACT 29323
JOB SITE
ADDRESS 79-818 PARKWAY ESPLANADE SOUTH
APN 609-380-023
OWNER
CONTRACTOR /DESIGNER / EN INEER
LA Q=, A DUNES, 350
CORNERSTONE DEVELOPERS, INC.
5005 CALLE-SAN RAPHAEL, M. BI
5005" CALLE SAN.RAPHAEL, SM BI
PALM SPRINGS CA 92264
PALM SPRINGS CA. 92264
(760)325-4289 CBL# 6867
USE OF PERMIT
SINGLE FAMILY DWELJ.J TG
SFD - LOT 55, PLAN 3ZCR. PERMIT DOES NOT INCLUDE BLOCK
WALLS; POOL, SPA OR DRIVEWAY -APPROACH
TRACT CONSTRUCTION 2,376,00 SF
PORCHIPATIO '45.00 SF
GARAGE/CARPORT 447.00 SF
a
ES'rmATED COST -OF CONSTRUCTION
138,376.50
4
PFIZ,A T FEE SUMMARY'' `
CONSTRUCTION?