BLDG (0310-140)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 p
17 6?9 D 04/30 L(
Date �� Signature of Contractor
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 an • swill maintain a certificate of consent to self -insure for workers'
compensate, las provided for by Section 3700 of the Labor Code, for the
performan@e o the work for which this permit is issued.
Se( ) I have and will maintain workers' compensation insurance, as required by
ction 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 LJOERTYMIJITUALF, Policy No. 'l A262DO04 "012Tf
(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 tie workers' compensation provisions of Section 3700 of the Labor
Code, I IRall.f rthwith comply with those provisions.
:)ate
` Applicant
'U `
Warning:, ailure 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 application and state that the above information is
correct. I agree to comply withall City, and State laws relating to the building
construction, and hereby authoAiz�}f�presentatives of this City to enter up
the above-mentioned property �for115spfection purposes.
Signature (Owner/Agent) ���" / Date lowot-
V,
T'1
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
��;t .ice 338.3
le' , • ,,7 / , e .JOB
SITE
ADDRESS i7
. ` 1��E21s'LLr.T.13
APN ._
OWNER
CONTRACTOR / DESIGNER / ENGINEER
WIRINELD tr PGA'WEiST BY"TOLL BROS,
'TO7. L BRO TIMM I14 O
81.3801SQ14'ND9 WAY
73-121 PRED WARD10 #100
LA Qmrrt, CA 92233
PALM D1MURT CA 92260
('760)6-14- 9699 MIX 302
USE OF PERMIT
85 L.P.& GAMDEN. N A.Ll , CITY Si'f';NDARD -
6 FT. WAM, 815.00 LIF
EMMAm Ct3n DST cOmTTt;LTmon
PERS T 3C+''i w SiiM"RY
CaRSTRUCfiION ME 301.000.418.000 $54,00
91:1"!x-TC)'rAI, f.014.ML'iM" 1034'", M. -I PLAN. 1.M
$54.00
IM9 Plrt`f+ PAf1:1 FES
$0.00
RMT FEFS VUR NOW
'Zim.
OCT 2 9 2003
�,. CITY OF LA pUINTA
RECEIPT
rutr BY J
//
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I DATE I INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
OX to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION I DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
POOLS - SPAS •
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final S 3 .!r- 4p- 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
COMMENTS:
C,
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
Tema. Use of Power