SFD (0308-099)50520 Los Verdes Way
0308-099
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
l`_ esChapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
I-- QLO
777699 1 W3012C
o Z r` Date , Signature of Contractor,..- A
J U S OWNER -BUILDER DECLARATION
HWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z_ ( ) 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).
Cl) () I am exempt under Section , B&P.C. for this reason
LO
C\IN Date Signature of Owner
ZWORKER'S COMPENSATION DECLARATION
C) I hereby affirm urider penalty of perjury one of the following declarations:
Lo Ir
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W = compensation,'as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q U (/) I have and•will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
cb z CarverId81?,I1 Y MUTUAL I'. Policy No. WA262DO04723012Tt
V
J
•(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall fort with comply with those pr v pions.
D te"-Z 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 t^
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.
fSign`ature (Owner/Agent) 'Ali """'Date?
BUILDING PERMIT PERMIT#
DATEVALUATION LOT TRACT
q. (, • C.' a $2 ,X74..2207 91 3Mt5'7
JOB SITE
ADDRESS SOL -520 LOS YOMS WAY
APN
772 -25G -03A.
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TOLL ARC1°1 IFER.3 .CNC
110U.1IRt'JT't3 li 1,U3WC
1.12I tZEtiCJ IBdE2123Cs 'I.001
73»121 1' ,RW 7VAR]NQ #100
CA 97,260
PALM DFOLM CA 922600
(160)674-9699 M1:,i#p 3832
USE OF PERMIT
SWO E ko.1 11,.5' T U Ei J E7' i
SFC! . IDT 91, I1i?IAZZ- A/4' PATIO, PNRMIT L OE3 'NOT INCLUGF,
BLOCK WALM POOL SPA OR. DRItf`FWAY APPROACH, 75% REDUCTION:
TO PL AN CHECK Flair VUZ TO MUL TIPIA ISSUANCE OF SAME PLAN '1 YPZ
CWTOM CONSTRUCTION 2 047,00 3F
PORCHIP.fATIO 313.00 SF
GARAc3FlCAWPORT 525,00 3F
Ma' ►' MIM COST OF CONSTi1;1:.TMON
253,:74,20
PF.' iWXr 1i ER GA09ARY
CONSTRUCTION PER 101.000,4.18,000 SI117830
Pi." CHECK F'EE 101-000-439-318 $7A4.97
IElIF,MIANICAL, FEE 101.0100.421-000 SI5O,00
ZLIECTRICAL rF,K` 101-000-420-000 $194,13
PLUMBING FEE . 101 -OW-419-000 $203.25
STROHICI MOTION P ,' - RESID 101-000-241-000 x$25.3$
ORADMO FTM,, 1011.00 0.423.000 X5.15,00
DlXF1,0PER IMPACT FEE $ 405,00
ART 1W PUBLIC PLAC M- - RUIL 2.70.000.445.01001 $134.44
SIM-T(YrA . CC'i1;3'MUC;TIOM MM PLA'N•.C, ITM
1,53fl,59
IESS 1✓R1 -PAM) FFYS
$0.00
6 2003:LA
qMO
QUIN` A
,INANCE OEPT.
DATE
. moi. /: _,
BY /
;
DATE FINALED
,,?sn,
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
nderground Ducts
Fours & Footings
Stab Grade
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath tQ
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beare
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING P
RVAL
Gas Test
Electric Final
Waste Lines
Water Piping
eater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 17
Encapsulation
Gas Piping
Gas Test
Appliatrces
-
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)