BLDG (0310-135)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
7'17699 B p4 092C
Date /. ,,nature of Contractor`. � f✓
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.
(h)' If le and will maintain workers' compensation insurance, as required by
Setction73700 of the Labor Code, for the performance of the work for which this
perm is issued. My workers' compensation insurance carrier & policy no. are:
Carrier LiTrERTY MUTUAL V Policy No. WA262,D004r=12 1
(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 Californi and agree that if I should become
subject to the wor ers' compensation po lv1(i of Section 3700 of the Labor
Code„I shal forth ith comply with those p o41 fo s.
.Qate u �'� ppiicant /r .�
Warning: Failure t secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, ,n
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorizefepres t tis of this City to enter upon
the above-mentioned property for speon urposes.
Signature (Owner/Agent) P d> . / Date
BUILDING PERMIT PERMIT#
0310«135
DATE VALUATION. . ' LOT ( TRACT
GasL`
JOB SITE •
ADDRESSL-�Tac�elw�i't.�7.L11a'
APN
OWNER `
CONTRACTOR/DESIGNER/EN 1NEER
WutF=,1PGA'V;rF it E;T TOO. M011.
TOLL MOTITM INC
81 m 8131,1 d31;�Ai�i S�il�.Y
7 3.17) FRED WARM #100
LA QIVINT.A CA 92253
PALM i31 VP.T GA 92260
(760)674»9699 L"'13IA 3852
USE OF PERMIT
C31 ER—kv. CT#1.U7�,TC3
83 L.F. 6' CtARLIErN WAL , CITY STANI)ARI)
:6 FT. VWAL6 0100 LF '
EST3MAI”. C09f OF b:C3X,S'. I TC.''.1'ION
2,1215.i1d3
.PE�EZ11g:E.1" k'3 S'C�lll t1r2�$t�'
CONSTRUCTKY R 101 -OW-41 B-000 S l.il0
SLTE-TU`TAL C0140!`FZ;.U'COM9 AND IES? AAT El-ia'C K
$54.00
.., 7.;M PRE -PAID nO
$0.00
Aar M.S DUE NOu IT '
$54.00
OCT 2 91003
CITY OF id
RECEIPT BY DATE FINALED INSPECTOR
CE
INSPECTION RECORD
OPERATION , DATE I INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
n►wuall _ Int 1 nth
OPERATION I DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings 11--i L
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final 3 0
Gas Piping
PLUMBING APPROVALS
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
COMMENTS:
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)