0308-108 (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
7'77.699 B . 04/30/2(
Rate Signature of Contractor 41'7 % a -
7 r
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 ($ec: 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 exempYunder Section 4 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 1,181DWY M'UTUAL F'. Policy No. W,A,262D004?2301WT
(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 prov, s ons.
ale: ! , ” X Applicant_4 %`7. ^• --
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to- comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) y`y .�Z404g_--''Date
BUILDING PERMIT PERMIT#
03tF8-Aim
DATE VALUATIONLOT TRACT
SZI!fl���9 •x1.4 30357
JOB SITE
ADDRESS 801...V' 0 VIA "DE•XC',(lI
APN
OWNERCONTRACTOR //DEESIGNER EEN&NNEER
hJLL B OWTERINC *iJJrBRO%nW WC
73-121 FREDWArrG0100 73.}.31, WARM100
PALM DFMT CA 92-260 PALM Dro' 2 .7 CSA 32260
(760)674-9699 C>3 E 3832
I I.SF r)F PFRAAIT !� /
SINGLE, FAMILY DW. U7jMG
SYI7 o L.U'i 114, CAMI'NBEWI. PR RMIT bOP-S NOT TNlCLUDE BLOCK
WALLA POOL, SPA OR.DR1VLNN.AYAPPROACK 15%REDUCTION TO PLAN
CHECK FeLP'1, UE TO M61,.TIPLE' 1SSUAMCP OF SAME PLA14 TYPE
CUOT01A CONSTRUCTION 4631.00 SF
E►OIkCHIPliTIdlll 399.00 SF
�
s,d
�3'1 1TED CCS' OF COMMS t'C'2'>fox
21%9W160
.PEht 11E U, S'UMT1R.'$t .
CONSTli,Uc^"3'ION P.RF 701-d3'J04-18.000 391099.40
PLA1a CHECK 7EE 101-0+30-d34- i 1, $ $21954
MECHANICAL ANICA.L FEE 101-000.421-000 $124,50
EtAC1`IS.ICAL 101-000-420-000 $137.99
PII,Uj(d.81-Nt3 Re 10.1 -000-419.000 $194=00
,
STkDWO MOTION F E - RESID 101.000-241-000 $22,00
ORADINO Ra, 101.000.423-000 $13.00
DEVELOPER IMPACT FEE $7,,405.10
ART IN PUBLIC PLACES - RESIL 270-000.445.000 $49,01.
SC,UB-TO'TAL, C098 -I fiI C fION AND PLAN C'FWCX
$4,236.44
LESS PRENPAL)• :2
; s0,00
SEP 2 6 2003
CITY OR
LAQUIWTA V
RECEIPT
BY
I DAW111fj1ALE
PECT
4 - ,9
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
If
Roof Deck—Exhaust
Fans
It
O.K. to Wrap .p
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 Pibg. Test
Final
Gas Piping
PLUMBING APP VAL
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
COMMENTS:
Final
Utility. Notice (Gas) ary
ELECTRICAL APPRO . LS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main'Service
Sub Panels 90
Exterior Receptacles —
G.F.I. lur
Smoke Detectors
Temp. Use of Power
•
r
Final _
Utility Notice (Perm) _�