0308-096 (SFD)50550 Los Verdes Way
0308-096
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
'7717699 B 04/30/2(
Date ' Signature of Contractor
OWNER -BUILDER DECLARAT ON
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 selPinsure 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 wor,,RTY I 1JTtJAL F Policy No. WA,26,2r,00472:3012TL
(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 l should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shII fo hwith comply with those provisions.
Date: 1 • Applican, '►
Warning: Failure to secure Workers' CobT ensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
'& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all'City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
I Signature (Owner/Agent) O Date
BUILDING PERMIT PERMIT#
0$-096
DATE VALUATION , LOT TRACT
3037
JOB SITE ADDRESS .No -_550 LOS; `' .l :&S 11fAY
APN 4172-250.011
OWNER
CONTRACTOR / DESIGNER / ENGINEER
T01.L .1BR0rkM,q INC
*rOLL PIO EZIS DTC.
73-121 XM WA TMG 4106
73 'FRED WARINO 4100
PALM DEW= CA X2260
PALM DESERT CA 92260
(760)674-,9699 awl$ 3832
USE OF PERMIT
SFI3 - LOT 84 DELI:c`&A.. PtRMIT DOES N'O.` rwdixot 13LOCr,
'NAIL, POOL., SPA OR I DIV AY APPROA.<'FJ, ,*$%a PXDIJCTIOW 'I'O PLIAN
CHECK M DUE TO MULTIPLE ISSUANCE OF S:KME PIAN N TYPE
CU `1'OhS CONSTRUCTION 3M7100 OF
PORCH/PATIO 253.00 S?
OARAGEWARPORT 625,00 Sz
ES1137111 d;t.'Jf'1! u (11O. 'r OF GCa.XY1TRUC,:''I°$'0iq
252,71,0.2D
1192M, T YER giiid/IVIA RY
CONSTRUCTION FEE 101.000.418-000 $1,113,01
MECHANICAL VEE 101.000.421-000 SISU,00
SLFCT.WC.A,.L VIA 101-000-4211-000 ¢1°94.13
PLUM81140 FRE 101.000A I9^000 .$203,25
S'TRONU MO TION FEE, liC,S10 101-000-241-000 $25.27
OitAI)1NC31't3.E 101-000_-423"000 315.00
'.
Di:'YI 1 OPER IMPACT T'LF
.APT IN PUBLIC PLA,(XS - R SIr 370.000.44.5-000 V 31178
101 AL GC)%1'vfMUCTIO1+3 AND FZ.A3 T CIECK
$4,543.70
LESS ;1 FX- TAM FEES
$0,00
IAL, FERWIr FEES DUE. NOW
SEP 2 6 2003 /
RECEIPT FINANCE , r BY ATE FIf A I
r • ,r ;
PECTOR
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 --Exhaust
Fans
O.K. to Wrap ..
F.A.U.
Framing
Compressor
Insulation -.i
Vents
_
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
—Final 1(4
Final _
BLOCKWA OV S
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBINGPROVA S
Gas Test
Electric Final
Waste Lines i
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
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles -0110
G.F.I. loov
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) : .
COMMENTS:
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