BLDG (0310-137)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
Date B � ignature of Contract r
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 r
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' s
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 YARE2tTY MUTUA L IF Policy No. W..A.26M0A 723012TI
(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' om ensa�lon laws of California, and agree that if I should become
subject t nth work rs' compensation provisions of Section 3700 of the Labor
Code, I sh'al oyrih ,tt <ly with those provisions.
•Date: ", Applicant
Warning: ail'
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 applicatioT and st to that the above information is
correct. I agree to comply with al�Crty, and/9 to laws relating to the building
construction, and hereby author 0� epresent tives of this City to enter upon
the above-mentioned property f,� j ; spegtion purposes.
Signature (Owner/Agent) �� �� 6' Date
BUILDING PERMIT
PERMIT#
^1 37
DATE VALUATIONs2www LOT
TRACT
ADDRESS al.4',5 2VFYT MA) VILLAGE
APN _
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
M.TJI MND @; PGA WMT BY TOLL L BROS,
TOLL i3ROTT WC -
81.380 LEGENDS WAY
73,1121 FRED WARAM M ma
LA Q11TU 'A CA. 92253
PAUA 159"Wr CA
92260
(7150)&74-9699 t','BLO
3832
USE OF PERMIT
t' map-F1I.13 )x1�12I?3t
90 LA 61d3ARDIM WA1,14 CITY ST',WfJir RD
0 FYI WIMIL
90.00 LF
Esrud iTM Cove OF CONSTTR17C'"I ON
2X50.00
PERMI' PW. SYTLI O". RY
CONSTRUCTION FEV 101-000-418-004
$54,00
SUB -TOTAL CONSi'aRUCTIt)N AND PIAN CHECK
$54.00
LESS PRE -PAID FM
MOO
°
'I'c P . .4"I'
ITTES DUENOWN
OCT 2 9 2003
CITY OF LA OUINTA
FIN. NC
RECEIPT DAA' ,_
DATE FINALED
INSPECTOR
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
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 r—
Bond Beam
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP ROVALS
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
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)
COMMENTS: