SFD (0308-101)50500 Los Verdes Way
0308-101
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
777699 .13 0413012t
Date % Signature of Contractorm 4!ed fiva-s.... IF
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.
( 1) 1 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 LIBERTY MUTUAL V. Policy No. WkU62D004W ,3012TE
(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'sio , ,,
ate: / a Applicant
! ._ ✓S63vs + •-»,..-.... ,
Warning: Failure to secure Workers' Co ensation 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, indemEn
& hold harmless the City of La Quinta, its officers, agents and employ
2. Any permit issued as a result of this application becomes null and vowork is not commenced within 180 days from date of issuance of permit, or cessation of work for 180 days will subject permit to cancellaI certify that I have read this application and state that the above informaticorrect. I agree to comply with all City, and State laws relating to the buil
construction, and hereby authorize representatives of this City to enter u
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)✓ s '-'y" ' Date G• .
BUILDING PERMIT . PERMIT ti
`\
DATE VALUATION LOT TRACT
5252.710: 2®' 93 30357 .
JOB SITE
ADDRESS 1sOt5 Vy .I:A
APN
772,ti.' -OlA
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TOLL RR.OTkMZ81.1dC
TOM BRA} i`I rKs WC
73-121 >:rlM WARING #106
73.121 FRMEWAR11400100
PALM DL; CA 92260
PAW :t DE, ' CA 92260
-(760)674.9679 CWL0 3832
USE OF PERMIT
' 1?A' eIIi;ll tXiF ; .1t1'fs
SI• D - I..0T 93, BEi.It.PfA PERMIT.009S 09S tJDT IiNNC1,UDE BLOCK
lil+'ALiA%:POO,4 SPA OR DR.IIfMAY APPROACH. 75% RI"DUCTION TO PLAN
CHECK FEjt DUE TO MULT1PL9ISSUA14CE OF SAME PL II TYPE
CUSTOM CONSTRUCTION 3,047,.00 SF
POR,MPA'1°IO ; 233.00 SF
OARlr,GMARPORT 625.40 SF
EST"<I11rD C.105T OF COI? SMUC1.'20N
X152,710.20
C014STRLICPION IEP, 101.000419.000 51,173.00
PLAN C IIEC'K PICS 101-000-439-318 $244.25
MECHANICAL FEE 101.000.421.000 11X89
CLECTPdCA.1, FER 101.000-4.20-000 $104.15
PLUM81" FFIE 101-000.419-000 $203.23
STRONG MOTION FISTS • RLSTO 101.000-.241-000 WXY
ORAD1NG FEE 101-000-423-000 WIN
DEVELOPER IMPACT F. F2 $3,409.00
ART IN PUBLIC PLACES •• .RESIT 270.000.445.000 $131,78
SUB -TOTAL CONSMUC•TTON AIMPLAN CFYJ— l
$4,543.70
IMS FRE -PA ID F1W •
MOO
d
-
I° nAL' P iVW. ..! "Mr..S a'UE KOW
$4,15A 3.70
SEP 2 6 2003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE //
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs,Underground
Ducts
Forms &FootingsDucts
Slab Grade
_
Return Air
Steel
Combustion Air
Roof Deck/Exhaust
O.K to Wrap
Fans
.A.U.
Framing
Insulation
Compressor
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
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 I
Gas Piping
PLUMBING PP VALS
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 do
Rough Wiring
Low Voltage Wiring
Fbdures
Main, Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
U fity Notice (Perm) Ll
COMMENTS:
L