BLDG (0310-144)LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and 0,310-144
U)DATE VALUATION LOT TRACT
04 W Professionals Code, and my License is in full force and effect. ti , ,� �2,23ArUt➢ X83$•3
License # Lic. Class Exp. Date �( r
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ADDRESS i APN
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Z r- D te Signature of Contractor OWNER CONTRACTOR / DESIGNER / EN (NEER
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U OWNER -BUILDER DECLARATION
o U.TJ . 6 @ PGA WEST BY TOLL BROS. TOLE. BROTF3Ii�t,.9 INC
J �p � ,,� � 73-121 IrdLE'."fi�A%t�ek�T��Ci �I4tJ
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 81.3190 LOGE T�/e
~ U) License Law for the following reason: LA QUINTA CA 92253 PALM DUER.T ::A 92260
Z ( ) I, as owner of the property, or my employees with wages as their sole tt760)674w9699 CBLO 3832
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code). USE of PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed OENEM BUILD1Ne
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 90 LF. 6' OAR.UZN 1,ifAIA, CITY STht< OAI2t)
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
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d Z WORKER'S COMPENSATION DECLARATION
C Cc I hereby affirm under penalty of perjury one of the following declarations:
0 ( ) I have and will maintain a certificate of consent to self -insure for workers' d PT WALL
90,0 LF
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U (X) I have and will maintain workers' compensation insurance, as required by
O LO Q Section 3700 of the Labor Code, for the performance of the work for which this
11 0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier I,1i3L{R`PY MUTUAL I: Policy No. IVA2621?UO472"12'eI ESa3]Wa4.'IJM C09I' OF CO[' STRI7C, TO.l►t' 2.2.WRO
°r° O MOM' PER SL1'I!!M+X4PY
J (This section need not be completed if the permit valuation is for $100.00 or less). CONSTRUCTION FEE 101.000„418.000 $34.00
() I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any maer so as to become subject to the
workers' compensation laws of Califor.la an'd' go a that if I should become
subject to the wor Vers' compensation prowls or Of Section 3700 of the Labor
Code, �a�l.forth �itl�,comply with th , se r is o�
,.Date• Applicant
Warning Fa rg 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 S B-TUEAL Cc7A�I"�3TRUCTION A>:�'!J PIAN Ck1r =< $54.00
whose request and for whose benefit work is performed under or pursuant to LESS PRE -PAM F $0.00
any permit issued as a result of this applicaton agrees to, & shall, indemnify D e
& 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 TOTAI _ .... "RES DIVE NOW 100
work is not commenced within 180 days from date of issuance of such OCT 2 s 2003
permit, or cessation of work for 180 days will subject permit to cancellation.
1 certify that I have read this application and state that the above information is CITY OF LA QUINTA
• correct. I agree to comply w�h�a`I,ICity, and State laws relating to the building FINANCE DEPT
construction, and hereby a thoorizp/representatives of this City to enter upon
t� above-mentioned prop,E fiorj h4' ectlon purposes. RECEIPT DATE, ' BY , t DATE FINALED INSPECTOR
e' Signature (Owner/Agent' Jl/ - Date �7 �:
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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 72C_
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final Z ? a S
Gas Piping
PLUMBING A PROVALS
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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: