0308-030 (SFD)LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14W Professionals Code, and my License is in full force and effect.
O =) ch License # Lic. Class Exp. Date f
oZ � rDate ? �4 � Signature of Contractors` :. �_ 0 t;`CID �•
Oti r
J U �' OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ a License Law for the following reason:
Z ( ) 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. f6r this reason
ul
N Date Signature of Owner y
OC\J
d Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il M I— permit is issued. My workers' compensation insurance carrier & policy no. are:
It Z Carrier I+ATjLONf1I, UN:lON p., Policy No. 1=5309
ob 5
Cd
J
(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
3 subject.to the workers' compensation,provisions of Section 3700 of the Labor
Code;;"I,s hall fdrthwith comply twiththose provisions:
Dates Applicant a,r_
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 tol.
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 pro erty for insgectiompurposes `
Signature (Owner/Agen��' �' I{
BUILDING PERMIT PERMIT#
TRACT
DATE VALUATION LOT 14
JOB SITE ADDRESS 81-9U IJ'ANM, DIMAPN
r
7N9 27 -1.17
OWNER
CONTRACTOR / DESIGNER / EN (NEER
O'FIMHOMES
% F-.A:e1CMEM
81.26-0 AVMM 62
81.260 ,AV. ME, 62
LAQUDITA CA 92833
1,A QUINTA CA. 92883
(909)833.8996 GSL# 6876
USE OF PERMIT
SFD
t.
SID - LOT 14, PL.AW 5320B,-•P,ERN1IT DOES NOT 1NCLit01P, BLOCK
WALLIAa P0014 8PA OR DRN'99P.AY APPROACH,
CUSTOM CONSTRUCTION 2,209.00 S
PORCHIP? XIO 245.00 V
GARA(MCARTIORT 541.00 OF
Lrsmw1''A13 COST OF CONK. -Mu mon
192,175.20
CONSTRUCTION PER 101.000.418.000 $965.00
PLAN CHI= lf-uE 101-000-439.318 $'7b5.34
1A ,CHAW1rAL• FZ 101.000-421-000 593.40
91,ECTRICAi.1 )� 101-000.420-000 $12-4.44
PLUMBtMO FEE $166-00
STRONG XIO•TIC}N HOM - Ftp IT) 101-000-241-000 $19.23
ORAT YNO FEE 101-000-42.3.000 $15.00
DEVELOPER INIPPLICT I' IA
. ""1` ifC"i70N AND PLAY CHECK
�1,5 N3.50
SGl I'P> -PA FEW
$0,00
D ..
SEP 12 2003 iPExla Ir FEES DIUM BONN
� 4,573-50
OF LA QUINTA
CITY
FINANCE Orr -PT.
ti
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
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
41V 4a
Drywall - Int. Lath
Final
Final 3— 0-0y
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
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
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: