SFD (0311-043)50460 Los Verdes Way
0311-043
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
'` tt rJS1 B ' `M.71lYVri
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
WORKERS 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.
I } RRTY Ut'J? AL F. 1ltirA162D0047Y;i IM
(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
• v f •j _ .1.
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 inspection1purpos%S _.,.
i.
Signature (Owner/Agent) u7r, 'c--: Date il'r_ lr,oi
i
BUILDING PERMIT PERMIT# '
DATE VALUATION LOT TRACT
r is .MO <r7 34357
JOB SITE
APN
ADDRESS
.50-4W Lc* VZ1WZ8 WAY
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TOLL 8,kCYi'HER11 LNC
'1:.)13,11801- I " C
73A21 FMWit RI.*:Q1l100
x3.121 FRiD'VVAMi;.f0100
PALM DFZF..R.T CA. 9212414-
PA1" 13XITFUZ11' !"A 922 64
C',"Mg 3832
USE OF PERMIT
011101.2FAkt ,lt
SYD - LOT Y1, CAAtsitNA,.k P> RUIT C?l ZS NOT I1.14..'LUJDt t43. XT.
WALLS, POOL, Ur AOR DrJ' V KWA Y APPROACH. 75% HI'MiCTION TO
PLAN CHWX "!,t DUE TO MUI_TYPLZ I2litJA14CZ OF %&MZ.PLAk4 TYPa',_.
CU13TOx1! yM«3'1'itUCTION 21u:i 00 SF
r:n
il^OR0VF.1kTJ() 4.00 By
OARACIMARFOR.T W.00 VF
--.!-
G iY
Y'T.tMKMD COST OF C. IDIII8TIUCTION
Zi:+, ►3.bQ
: r • Ott; IJI,tt4d
CONSTRtisMON iS'1rE= 101.040.418.01310 $1,419,30
P1_6 z CHE" it VE 101 _0001.141.35.'-3 i 1, $71t3e
MECHANICAL Y O-WO-O(V S124.91
*101-♦ J
tL9CTPJCAI. M'6 101 -OW -420-00,11 $07.991
KAJU RINOM 10. -OW -419 -VX) SWIM
3TRONO MOT1014 vE.P. . x`£:8411D 101-OW-241-OCO $3100
GRA.DY401TE 1014n00-4:13_WX $15.00
DTVI -L OPIER JuP.tc Ff.1!, $2,403.00
ART IN PUBUC Pi..ACiR - fiamoi; 270-LOD-445-w") $+41.91
J--. Ct3N'P!i'RT.SMOW AND PI" CIfiXX
$4,236.44
t' RVU pR&r' AM FM
S0.00
TOTAL Y910M 7M DUE NOW
S4,2XA4
RECEIPT
DATE
BY
DAT IN ED
INSPE OR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
-underground Ducts
Forms & Footings
Slab Grade j
Ducts
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 & Controls
Party Wail 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 Plbg. Test
Final
Gas Piping
PLUMBING P OV
Gas Test
Electric Final
_
Waste Lines
Water Piping ..
Heater Final
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 m
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)