0305-027 (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 Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury thpt 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',Sectidn 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 :,i'1'A7E !t? NI) Policy No. MU.24-4113
(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,
1 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,. l shall forthwith comply with those provisigns
- . /
-Date: Re n 2 Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the LaborCode, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) , f �a� ! Date
PERMIT #
BUILDING PERMIT
DATE VALUATION P.a.1 4a 6,60 LOT 14 TRACT 29323
JOB SITE
ADDRESS 1'J�^:ti'krLA1�f J�alr'P�j`FAIt. iQi�l�s'.
APN
OWNER
CONTRACTOR / DESIGNER / EN &NEER
:[.,tr, Q!MA•7 rrA D:s!�.1pp�FYY.ai:i's�e3yySftf0y, INC.
CO7:1ftREASiTT•OWYl�.,DE;'�.�?c�l:rl:"%�:+ir'�tRS�,.�T.�# ..7 _
9
vC� 1
.`005 �.�+�aelet.Xt E7.E%t'C C..f'� 3.[] 127 •; srn, R1 .
P6.i_ Y Hs`MU1 G11 C`..,i. i.nUA
PAIN e+'Pir'..j.NG* Co.. 92764
(.>867
USE OF PERMIT
:>1'YB - 1171' 14, dT.*.pJ�VJ At:{? 1yi ='t 3AW�LrrtrL.r JLv .
(7• r CiJtpsry$yry�r ♦a
:TRACT t:-0A,9TRUC` IOW �,r3.00 SF
PGIN" C H/FA :.'ft.;
S •
r
ME MM FEF 90MUR
I► JO4 CHICK tIVIR 3 tyl -000-439-318
bR1TCYLANeti `AL VEX 101-000-421-000 M 0. S'tt
ELECTRICAL. 1+7 N 1(}j..(*0-4240•-,GQ,0 $415,35
P141A13rN(t 1.,.Ts.K 101-NYD -41 �-000 $140,7S
:3T,9C440 MOTIO'hil FEE - RP"Is!.D 101 _000-241
GWANG 315.0
+
' 1
9UR-TI ')TAT., COl TRUCI` 014 ARM PT.139CIFFACK
$4,0371.10
I,�.�)w i?JT,,--F.AJD MTV
$0.00
TU' L144. ��i�:17(' IMIS DIUN NOW
$4.(* 730
RECEIPT
DATE
BY
D INA
NSPECTOR
411,
O3>�'+-ItIM
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel i
Combustion Air
Roof Deck ti ,/
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing ly
Insulation
Compressor 711 L -N
Vents .10
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 PPROVA S
PO - 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 APPOVALS
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 e7 j
Pool Cover
Sewer Connection U
Encapsulation
Gas Piping
Gas Test
Appliances -
Final
Final
Utility Notice (Gas)
ELECTRIC LAP OVA
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:
V v
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 11130IN
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:
( ) 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 urider'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:.
( .) 1 "haye 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.
( ) 4 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 h&''are:
=
Carrier STATE FUND' °' Policy No. - 1703624-03
(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,
1” shall not employ any person in any manner so as to become'subjectto 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
Warn'rrig: Failure to "secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fires 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
BUILDING PERMIT PERMIT
DATE VALUATION $122,466.60 LOT 14 TRACT 29323
JOB SITE
ADDRESS 79-869 PARKWAY ESPLANADE SOUTH
AP" 609-380-023
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
LA QUTATTA DUNES 350, INC.
CORNERSTONE DEVELOPERS, INC.
5005 CAL,LE SAN RAPHAEL, STE. B-1
5005 CALLE SAN RAPHAEL, SIE. Bl
PALM SPRINGS CA 92264
PALM SPRINGS CA 92264
(760)325-4289 CBL# 6867
USE OF PERMIT., - -
SINGLE FAIRLY DWELLING
;,
WALLS, POOL, SM OR DRIVEWAY APPROACH
TRACT' CONSTRUCTION . 2,083,00 SF
PORCH/PATIO- ' 45.00 SF
GAR: .AdE/CARPOR.T 447;00 SF
ES=dATED;GOST OF CONSTRUCTION122;4466.60
PERMrF.FEE SUMMARY,
CONSTRUCTION FEE, _ 101-000418.000 $720,00
PLAN CHECK7.EE- 101-000-4397318 $588.95
MECHANICAL FEE 101.000-421-000 $40.50:
ELECTRICAL FEE 101-000-420-000 $115:35 .
PLUMBING FEE 101-000-419=000 $140.75
STRON&MOTION FEE - RESID . 101-000-241-000 $12.25
GRADING FEE 101.000-423.000. $13:00-
DEVELOPER IMPACT FEE $2,405.00
SUB -TOTAL CONSTRUCTION AND PLAN CMECK
$4,035.80
LMS PRE -PAID FEES
TOTAL PERMIT FEES DUE NOW
$4,037.80 .
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR