0305-030 (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.
Licensee# Lic. Class Exp. Date
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).
( ) 1, 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 O'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 STAT1? FUN)"', Policy No. 11,43624-03
(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 of%the Labor
Code, I shall forthwith comply with those provisions.
.,Date:.S• : s� ��'• Applicant. ✓'.--' r /' �i
J Warning: Failure to secure Worke'rs' CAcoverage is unlawful and
§Mall 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, 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. .
i
(Owner/Agent)i" Date
BUILDING PERMIT PERMIT
�f�
DATE VALUATION $107;.:E.003rLOT TRACTJOB
ADDRESS ESPLANADEr�'OVER
APN )9380,,>�n
OWNER
CONTRACTOR / DESIGNER / EN INEER
LA Qt;1 TA UT3) i0 nX.
Ca.K'tMr9tT3,ELCEzIf, -WC. WC.
10P.S 1,'APF1`.iTE- P,:-
5005CqILEnARAT11gAM9M.51
PAl,:'t`.!. &-`ugGS CA x,212,64
P.KLM, M, �s"IRWC,,r8' SQA 92244
USE OF PERMIT
SMD, I",,";!' K PL.Alq ;t::, 1Ni.;rd' 1HULLU&MoUL:K WAALIA,
}'OULI 114E -1A OR D:1I1X,7,RAY APPROAC ,.. ` 5WREpl. CTIOW TO ?I.&i (,"HFIC K
FLEE 1311F TU OF aAiAS ►YPI , .•
TRACT f :' 1,019OCTION 1,ai uo 14F
GAP A- GF.dwkH'' 0: 423.00 Sk
coff or CC.I,WIPW,"S 011 3t� r,aE�t3.7di
I' ! F3M EAPY164.e :Ky
C.0 NEri'<tiUCTION Ff",f. 7 41 n000.418.000 1667.30
Pi.AN CHECK FEE I0 I- 00%1_439-31€1 $t�'i.u�
MOCIiANICA].FER 101•-000-121.•400 V7,00 A
Fl..EOT XICAI, M, S C1 -0t, vi -420-000 005-21 .
?LL'Ia D;H0VU, 1.01.000-41 -004 3140.74
MONTIONY P?',.L' - lRnw 101 -000 -241 -WO
0RAJX1 ,kf MIX 101 w000-421-000
i1P:�FJ!:f.�..6.t'k:-?� lMs,•t�'^.:° �n„g �Z,dB;'i.tL9
. r"'4A
,r.
t.
uf;-7f.Yl'AL C0• ',RUtM 01TAND a���•JJEpCy:. S: ,5,211 .$q0
p�k'd��..77A,ICf
gp� �
I,�f:. R1 HI .P r F's am. How
L
i ,:-
RECEIPT-"---" "
BY
D FI
I PECTOR
]DATE-----
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings'
Slab Grade I
v
Ducts
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap i
Framing
Exhaust Fans
F.A.U.
Compressor
Insulation I
' " dmoo or
Vents
Fireplace P.L. i
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath i
Drywall - Int. Lath
-�3 S
i
Final
Final
BLOCKWA
L APPROVALS
POOL - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam 1
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP ROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping r
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer ConnectionEncapsulation
If
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:
i
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 lam 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).
as owner .of the property, am exclusively contracting with licensed
contractors to -construct the project (Seca 7044; Business & Professionals'
Code),
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKERS COMPENSATION DECLARATION
I hereby affirm•' under penalty of perjury one .of `the following declarations:
O 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 thework.for which this permit is.issued.
I'have.and;wili . maintain wojkers' compensaiion .insurance, as required by
Section 3700 of the Labor Code, ,for the performance: of the, work forwhich, this
permit' is issued ft workers' compensation insurance carrier & policy no,.are:'
Carrier. STATE.FUND Policy No. 170562'4-03
(This section need not be completed if; the permit valuation is for $10000 or. less).-
(„) 1 certify that in the performance:of the work for which thispermit 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.withthose provisions. "
Date: Applicant
Warning: Failurestosecure Workers' Compensation* coverage is unlawful and
shall subjecf an employer to criminal penalties•and civil fines up to $100,060, 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 agreesto, & 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 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 PERMIT0305-030
DATE VALUATION $107,100.70 LOT 11 TRACT 29323
JOB SITE
ADDRESS TH 79-917 PARKWAY ESPLANADE SOU
APN 609-380-023
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LA QUINTA DUNES 350, INC.
CORNERSTONE DEVELOPERS, INC.
5005 CALLE SAN RAPHAEL, SIE, B-1
5005 CALLE SAN RAPHAEL, STE, B1
PALM SPRINGS CA 92264
PALM SPRINGS CA 92264
_(7601325-4289 CBL4 6867
USE OF PERMIT
SINGLE-FANT L.Y DWJELLING
SFD -'W..T 11, PLAN 1C. PERMIT DO O :I IC
POOL, SPA OR DRIVEWAY APPROACH.. 75% REDUCTION TO PLAN. -CHECK
FEE DUE TO MULTIPLE ISSUANCE OF SAME PLAN TYPE
TRACT CONSTRUCTION 1i806,00 SF
PORCHIPATIO 53.00 SF
G. ARAGEICARPORT 425,00 SF
ESTMATED COST OF CONSTRUCTION
107,100.70 ,.
PERMTT.FEE SUAMARY. <
CONSTRUCTION FEE ibi-000-418.;o0b 5667,30'
PLAN CHECK, FEE 101-000=439-318 $137:63
MECHANICAL FEE 101-.000,421.000 $47.00
ELECTRI CAL- FEE .101•-000-4207000 $105:21
' PLUMBINO TW 101-000=419=000 _ $1.40,75
STRONG MOTION. FEE-.RESID 101-000;24.1-000 ; `510:71
GRADING FEE 101.0.00-423.000 .815;00
DEVELOPER IMPACT FEE $2,405.60
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$3,528.80
LF -33 PRE -PAI FEES
$0.00 .
TOTAL -PERMIT FEES DUE NOW
$3,528.80 -
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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Serving Coachella
LonValley 8inoe7982
Contr'actors Lio#419309
C-", C -B'? . CALIFORNIA COR ORATION
78005 Wiid,ont Or. suite 1"0.4
Palm Desart , CA. 9221 1
WWW. `dasartpa- red 1sapooiscv.corn ,
760-360-7400
LENGTH 35 FT__ WIDTH 18 FT.
POOL SQ. FT. 425 SPA SQ. FT. 38
POOL PERIMETER 92 FT. SPA PERIMETER 22 FT.
DEPTH: 3, TO 4 TO 5
EXCAVATION: DECKING:
Special Misc Decking by Sq. Ft.
Finish Color
Cant. Step Porch Step
Deck Drains: Yes No
Stub: Yes No
Drain to Street. Yes No
STEEL: Tie into Owners Ex. Drain Line:
Special Misc: Curb Core: Yes No
Decca Drain: Yes No
Special Misc_
POOL PLUMBING: ELECTRICAL-:
Special Mise. Special Misc.
SPA PLUMBING: MASONRY:
Special Misc. Spillway Type
Property Line Wall
Fire Pit
RBB Facing
Equipment Lyall
GUNITE: Stone Steps
Fireplace
Special Misc. Veneer on Outside of Spa
Stone Waterline
Special Misc,
WOOD TILE:
Special Misc. Group 1,2,3: YesNo
Tile Trim: Yes - No
0 Steps 0 Benches 0 Love Seats
Special Misc.
IRON
Special Misc. PLASTER / PEBBLE:
Type
Special Misc.
JOB#
ADDENDUM$ DATE SELECTIONS
3
STONE
2
BOULDERS
3
DECK COLOR
4
PEBBLE/PLASTER
51
STUCCO COLOR
6
WATERLINE
71
GROUT COLOP.
SCALE: REVISION: 04
0, 4 81 16' DATE: 07-26-07
SALESMAN DANIEL H_ LOT NO. 69
MAP ROOK REF. TRACT NO.
Prepared Especially For: CZERWINSKI RESIDENCE
Street 43-244 PARKWAY ESPLANADE
City LA QUINTA CA 92253 (MCSIAC AT ESPLANADE),
Phone (612) 384-0562 —con Phone
Office (760) 834-2366 Fax
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