0305-022 (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
606486 .0 11 /3)xV.
Date ._,i ?`,,�, f 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 WATF FUND Policy No. IW -5 24-03
(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 df the Labor
Code, I shall forthwith comply with those provisions.-._."
r ,-Date: Applicant-
Warning:
pplicant 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, interestfand 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 1.80 days will subject permit to cancellation.
i
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) rZ :%' �- "' :' A Date =_- '
PERMIT #
BUILDING PERMIT
x.172
DATE VALUATION f.�,:o Ctral>'�� LOT' TRACT
ADDRESS �'ii.iEitii.Yt"l :Ad%x�, SO�.
7
APN
OWNER f —
CONTRACTOR / DESIGNER / EN INEER
LA (ZUi-N-,rAT)tsl FF.I _3.50,,.N(,.
Comm.
500:, CAS'LE lm'f RA-T-11fi` C., ,> z, B-1
5005 sv,AU,A+ SA N .ttr°al'HA°..+_�..; ST.6.1: 1_11
1y3iLM SPRINM t<pi 92264
PAi. AES. K9WG,'4
Ctk 92264
USE OF PERMIT
t31..1.I�lr,(iFi::C
SY0 - L07 SX, KLA.M 1 AiL I'IY,1`4#1Ir Dum5 Nor.ANV. lioze i11 UL:Y.:
'WAJA8, ':P00z9 ,! A CrR DRUFMAY APPRO..ka H
VORCr.rDtIO
5n
jARtC Yna2RT ,.0000fa
Es&JIf11w1'Jaill COW., OF t'C�i«i5'4'R`8>4 `FlSJE�
4.i; i',ii�,7C1
CON3`('RLt(:'i10V FFF 101.000141 f p•LC,,(t %67.50
PLAT4 !HIP.:':I.`;. KLIZ 1 1-, $550.5+0
P, RC°HANIC.,1 L F12. 11)141(hi-4-21_030 V7,00
M,WFRIC;.AL e t'l '10 F -000-42LI•--000 $105.21
PL,tTh BINO FEW 10 •'000.4.13-000 $1401'39
S'PROM }I 0710W "M - R&SID 1W-000-241-000 $10.71
o1x�1�1�ac1:�� sUt :.tsncl��.���v�0 s►s.c�o
OLVFLf-)PZR IM&AA,T PtS1
MMU Py,
=t:F 3$.1MIr FTYS :DUR )'3s`: W
6-3,441.6 7
RECEIPT
DATE
w
BY
DATE
CTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade V
Return Air
Steel
Combustion Air
Roof Deck 11 In ka
O.K to Wrap
Exhaust Fans
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath 1
Final
Final
BLOCKWALL APPROVALS
POO S - 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 PP OVALS
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
Encapsulation
Gas Piping
Gas Test — �3
Appliances
Final
Final
Utility Notice (Gas) - P �z
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
4019 U6
Final
Utility Notice (Perm)
COMMENTS:
- t Iw
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/N
Date Signature of Contractor
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).
( ;..)... 1p,!as owner- of.dhe=property, -am, exclusively. contracting- with -licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code)... "
O I am:ezempt•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'
compensatiori, as'provided for by -Section 3700 OVthe Labor.Code, for the
performance of the work for which this permit is issued.
( ) +have and willF maintain Workers; compensation' insurance, as -required by.
Section 3700 of the L:a6or'Code,.for the performance:of the work.for'wAc*F this
permit Is.issued. My workers' compensation insurance carrier &.policy;no.-are:
Carrier STATE FUND Policy No. 1705624-03
(This section'rieed not be completed if. the permit valuation is for $'100.00 or. less).
`('j"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
snail subject an; employer to criminal'penalties and civil fines up to $100,000, in
additionto 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
BUILDING PERMIT PERMIT#
0305-022.70
DATE VALUATION $107,1
LOT 57 TRACT 29323
JOB SITE
ADDRESS 79-850 PARKWAY ESPLANADE SOUTH
APN 609-380-023
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LA QUINTADUNES 350; INC.
CORNERSTONE DEVELOPERS, INC.
5005 CALLE SAN RAPHAEL, STE. B-1
5005 CALLE SAN RAPHAEL, STE, B1
PALM SPRINGS CA 92264
PALM SPRINGS CA 92264
(760)325-4289 CBL4 6867
USE OF PERMIT
SINGLE FARMY'DWELLING
STD - LOT.57; PLAN IAR. PERMIT DOES NOT INCLUD&BLOCK
WALLS, POOL, SPR OR DRIVEWAY APPROACH
TRACT CONSTRUCTION 1,806.00 SF,,
PORCH/PATIO '53.00 SF-
PAROElCARPORT 425.00 SF
kS.TIMATED COST OF, CONSTRUCTION
107,100.70
PERMTr.FEE 9Uh04ARY
CONSTRUCTION FEE 101-000-418-000 566'7;30
PLAN CHECK FEE 101-000-4397-318 $550.50
MECHANICAL FEE 101-000-421-000
ELECTRICAL FEE 101-000-420-000
PLUMBING FEE 101-000-419-000 S140.75
_
STRONOMOTION FEE • RESID 101=000-241.-000 $10:71
GRADING -FEE 101-000-423=000 E15.00
DEVELOPER IMPACT FEE $2,405:00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$3,941.67
LESS PRE -PAID FEES
$0.00
TOTAL PERMIT FEES DUE NOW
$3;941.67
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR