9907-421 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby.affirm under penalty of perjury that.l 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
41Tr
�Date Signature of Contractor �}
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that 1 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),
as owner of the property, am exclusively.d6htraCtin§ Witn 116096d
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O 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' compensation' insurance carrier & policy no. are:
Carrier Policy No.`
(This sect onne dFno be completed if the permit valuation467-9,94V40120 .0less).
O 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' compensat99.0AWE7
rnia, and agree that if I should become rov sions f Section 3700 of the Labor e,pr�vti'signs DL v '� "' .
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 auth�rize representatives of -this City to enter upon
the tiove-mentioned property or insp etio urposes. e {
`dignature (Owner/Agent) Date '
BUILDING PERMIT PERMIT#.
DATE VALUATION LOT*.�7 42 TRACT
23953
JOB SITE
ADDRESS^� _
OWNER -- -- _ CONTRACTOR / DESIGNER / ENGINEER
OL63'.H.r' NT AND VLLIAMS AS,,Oc , .IXC. OLIPHANT AND WILLIAMS ASSOC:., INC. .
777-9 kVrENGF OF"I.A STATES 77••900 AVE €:fF CW THIS '..;TA'rE- S
PALM DESEli.'i' CA 92211 I',t1LM D:GSERT ; QA, 0-22,11
�64j:t C.:Bl,# Ml -
MA
USE OF PERMIT
i
wryyr r: w. a a r. r as y.rr.°.rs. .v
SM - LOT $6, PLPW Q, PENNOT ,i OES NO E' INMUM F+'LO(.-, C WA;1 OR 4,
POOL. 79%v PLAN CHECK f'kt'� FOR.6lit.Fi,TIPLE ISSYJkNU., OF SAt:4E. FLAN
ViY7: _ T
-y'2�
it
`rRA.C°d' C0 NS'1'1Rt.1C'l 1aN 2,09 3.00 AFF
,
i'ORMIPA,TIO 70.00 .SE
t c
C rARArWCA ((OXT 679.00 9F
TY '({ Hyy�y,/{�YyDCon,0 may'omsruixf aN
-ItS,17
+tr.
' PER -3441T FEE SUMMARY.
CONSTRLTC'.xiON YW 101.5100.41.$-000 s741.CA)
Pff AN 01fliCK FU !Ot-000-439-315 $04.30
NIECHANICrA 1;` IJ1 t�l).fl-�t2:1-i?OC 5G.0(2
ELF,Urf 1f 4,L FV, 10140 420-000 $135.41.
PUU1\M'iNCr .F9E 11A1 f14- :1 -OiN3 $.154.fX3
JT.K(}C�fC3',t410',T1ON t'L�d� - �51:1,� 101"lfQO.2Al,�ltl0 $g2:f12
OPLAOIINQ F> Z 101.401142:140) $20.00
E?JFd�AaT1t[TC� i ifRlr FE7 2244W-443,342 .. _. `5.2,'€f62.57
ART PN PC:f13 IC #rLA.CES - $70.40
U f -I `A1>s C� :S'4 .�C'Ti N ��N3J t Lxl ! Ci IFG
$4 2:10?0
LESS PRF-PA1D.F'1',Y N
S0.00
TO.l 1 PERMIT F '. _" g3il�rti��.
S4,210,70
RECEIPT
DATE
B/
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
q -g- 99 G
Ducts
Slab Grade
of Q=�9 `Cj7t
Return Air
Steel
Combustion Air
Roof Deck
% —
Exhaust Fans
O.K. to Wrap
�y�.-L rj�
F.A.U.
Framing
Compressor
Insulation
- ?.lo- pjj
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls -
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
2. -7 .QQ
Drywall - Int. Lath
_ �Q
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
Gas Piping
PLUMBING APPROVALS
_
Waste Lines /
Gas Test
Electric Final
Heater Final
Water Piping
(
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Sewer Connection
/' _
/Z �"' ' t�
Pool Cover
Encapsulation
Gas Piping
Gas Test
_
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 -
Utility Notice (Perm) ..