9807-412 (SFD)LICENSEUCONTRACTOR DECLARATION.
l,hereby.affirm u6der'penilty of perjury that I'am licensed under provisions'6f
Chapter 9 (commencing with Section 7000).of Division 3 of the Business. and
Professionals. Code, avid my License is in full f6rce' an - d effect.'
License Lic: Class.' Exp. Date
41
14!
I
Date IteSignature of Contraqto
D t_
OWNER -BUILDER. DECLARATION
! hereby affirm under penalty of perjury' that'l,am exempt fro . m the Co I ntrac . tor's
License Law f6r.the following reason: -
{,.as owner of.'the p"roperty, or my -employees with -wag6i as their sole
cornpefis'ation-will do the work, and the structure is not intended pr,offered for
sale (Sec. 7044, Business & Professionals Code). -
1, as. owner of the 'property, am exclusively contracting .with' licensed
contractors to 'construictthe project (Sec. :7044, Business'& Professiohals
Code).
O I am exempt under Section B&P.C. for this.reas'on
Date' 'Signature of Owner
WORKER'S COMPENSATION. DECLARATION
I hereby affirm under penalty,6f, perjury 'o.ne.,of Pe, following declarati6hs.
'I have and will maintain a certificate of ' consent . I to self -insure ' for workers'
compen.sation;: as proy . 'ided for by Section 370"6 of -�theLabor".Cod.e,' for'-thb
performance of the work for which this permit'is issued.;,
I have and will. maintain workers' compensation insurance, as n4quiriid'by
Section 3700 of the Lab . or Code, for,the performance 'of the work for which this
permit is issued., My, workers'. compensation i6urance.darri& I& Obli*cy,no:.. are:
Cartier Policy,Nd.
xlr' Ott; F -01410
(This section need not I be completed if the . permit valuation is for�',$100.00,prl.ess)'
O I certify that in the 'perform ance'of'the work for which ihis'pe'rmit is. issued,
I shall not employ any person in any- manner so as to become subject to the
Workers' compensation laws of Califomia,-and agree that if I should become
subject the workers' c6mpensati9p'.proVision's' of`Sd8tion 3700 Of the Labor
-7•
•.,
Code 'I stlailk1p1h1ith comply with !�b-se ponv"OOM,
11 (�,J. .4, , -:
Applicanti��
Warning Failu I re , to secure Workers; Compensation I coverage: is unlawful and
shall subject anempl6yer to criminal penalties and civil fines up to $100j000, In
addition to the cost of cbmpensation,'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. ; cdnditions avid -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 isperformed under &pursuant.10
any, permit issued as a, r6su It of this ap p licat . on agrees to; - &'shall, indemnify
&'hold harmless the City of La Quinta, its office'rs,'.agerits and employees.
2. Any pe - rmit issued, as a r9sufi of this iapplication'.becidrnes null and void if
Work is not commenced -within 180 days from, date of issuance o(such
'permit, or cessation of work for 180 days ;will 'subject permit,to *c:ahcellation.
I certify that I have, read this application, and -state that the ab6ve,information is
Correct. -I agree to comply with all City, and State laws relating -to the building
construction, and hereby 46thoirize representatives of this City to enter -upon
:th
ave -
e a mentioned property -fo n, inspection purposes:
L0V
I, ignaiuie (Owner/Agent) 'Date
BUILDING PERMIT PERMIT#
DAT% VALUATION LOT TRACT
JOB SITE
ADDRESS 79. J6 Q VU V"ISTA NPE'RRS
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
irNf V,JyJ,J A 'A
C .,
"OF
61 ;�I'
NU QF- iVYRS.''
-11 W
7 -9WAVENUE ItE M T.S
PALM DESURY CA 922,11
PALNT CrUt GERT CA 92211
T
:�MQ)34�47 K C MU 57
USE'OF PERMIT
SING11 FA.MiLVDaiELLINO
a b tt LOT
,P001— 03ECK FFE OF IfiAbJEVLj�,N
TYPE
'MACT C014f,1RUCTION'
V&awoVic
q% w
A
'RK11T YER, S
4z� t f,
rC()NQYFRUCF10N FEE
ky.-
AN C. f M 111. K FEB.
NXIC t, ZPANI-CAt". t 01 00Q-42 14000
ELE
PLUW31340 FIX" _011110;44194*0
,VROWUNKY ON FM -JWS1,0 10.1 -(*0-74j,4)N1
GRADING FIT
P�Rr!.'CJSU PLAN nnho
1-4,3134 PT I C `F'R -.R ISM 701_(A10_ZS5_W,' ) "sqow'
37:'41<I+..,R Nl?"
TNS".'UCTIDN ANDVLAN fTff-(�K
T 'S
L.HS*S 1.-'1Uh-.PP4D 1� -Xi
7
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
_�46,
Exhaust Fans
O.K. to Wrap
I pit.
F.A.U.
Framing
Compressor
Insulation
Z — 1 S— 00 4
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Partv Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
t - t - o DLJ
Drywall - Int. Lath
tA
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
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
W `
Encapsulation
Gas Piping
Gas Test
. V7
Appliances
Final
COMMENTS:
'
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 -S-- -vj . ae
Utility Notice (Perm)
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.
Licens6#57117 ic. Class Exp. DM/31/20(
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).
( ) 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' compensationinsurance carrier & policy no. are:
Carrier STATE FUND Policy No. 467199-0000120
(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: 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 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
'
Yy
BU I ^M M PERMIS./i.o,7-412 •
F 1 1
25953
DATE VALUATION I JJ UT
OT 77 TRACT
JOB SITE -
APN 4 •/ - J
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
nT TDT..r A NTT A T.Tn AATTT T 'T A AAA A rens TNT('
VL1111I11V 1 r11 1/ VV 1L,1a Jr 1V1U L1L0 V,I...� 11V1..
nT TDu A NTT A NTn \1rTT T T A T RC A C4Znr1 TNT('
VL11 11111`/ 1 f11V1J VYI111LC11YlU LlUUVI_..j 11.0-
77-900 AVENUE OF THE STATES
77-900 AVENUE OF THE STATES
PALM DESERT CA 92211
PALM DESERT CA 92211
(760)345-2626. CBL# 5203
USE OF PERMIT.
SINGLE, FAMILY DWELLING
SP L) - LU 1 7 7, PENN Es, PER MI I DOES NO I TIN CLUDE BLOCK WArL UK
POOL. 75% PLAN CHECK FEE FOR MULTIPLE ISSUANCE OF SAME PLAN
''TYPE
TRACT CONSTRUCTION 2,292.00 SF
PORCH/PATIO 120.00 SF
GARAGE/CARPORT 638:00 SF
ESTIMATED COST OF CONSTRUCTION
138,556.40
PERMIT FEE SUMMARY
CONSTRUCTION FEE 101-000-418-000 $776.00
PLAN CHECK FEE 101-000-439-318 $165.49
MECHANICAL FEE 101-000-421-000 $66.50
ELECTRICAL FEE 101-000-420-000 $150.48
PLUMBING FEE 101-000-419-000 $211.50
STRONG MOTION FEE - RESID 101-000-241-000 $13.86
GRADING FEE 101-000-423-000 $20.00
INFRASTRUCTURE FEE 225-000-443-342 $3,081.61
PRECISE PLAN 101-000-441-345 $25.00
ART IN PUBLIC PLACES - RESIT; 701-000-255-000 $96.39
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
$4,606.83 .
LESS PRE -PAID FEES
$0.00
'TOTAL PERMIT FEES DUE NOW.
$4,606.83
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR