0308-090 (SFD)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
'777699 B .04/30/2(
,Date QA 4 Q 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-
_WORKEWS 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.
(i�)' 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 LI$1r:RTY MUTUAL F Policy No. WA262DQ0023012TI
(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 the workers' compensation provisions of Section 3700 of the Labor
Codef,l shall fo hwith comply with those pr isips.
,Dirte: Applicants ��'
Warning: Failure 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 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.
Signature (Owner/Agent)--�^ Date
BUILDING• PERMIT- PERMIT#
DATE VALUATION LOT TRACT
9:23 3*7XV.50 52 30337
JOB SITE
ADDRESS C:�_-`VbRA1q® -DraVLr
APN
OWNER '
CONTRACTOR / DESIGNER / ENGINEER
TOLL B32.017MMkR3 INC
TOLL BTtC73 _Wl W71
73-12'1 U t�J TN4 4+f7 Ui1
7.3-121 "X.D WARNG, #100
PALM D&RDIrf CA 92260
PALM DF -OF f CA 92250
(760)574.9699 CB,L# 3832
USE OF PERMIT
SINGLE FA:MtT Y DZFd'.EL1;,ING
S.f'D - LOT 52, SERO -NA -A. PERMIT DOES NOT INCLUDE SL OCY.:
WA.LL;% P001� SPA OR DfUV EW' AX APPROACH. 7596 PfDUCTION TO PLAN
CHECK FS; DUE TO MULTIPLE ISSUANCZ OF SAMR PLAN TYPE
CUSTOM CONSTR,1 C-fION 2,800,00 -Sp
PORCH/PATIO ; '175.06 SP
OAr AGEICAxPORT ; • 610.00 SF
3 ST)IMATED COUr Off' C0,119ji1 OC nOr1
xx's,-mm
CONSTRUCTION FER 101-000.418.000 $1,108.50
PIAN CHECK FEE 16-1-000-4.3.9.,318 $227.00
lC4 XHANICAL FEE 101.000.421-000 X111.50.
ELECTRICAL FSE 101-•000.420-000 $165.20
r'1✓1J:MBINC . VZE 101-000-419.000 1184.00
STROi1+;1 lUiOTIO14 VFW - RESITS 101-000-241-000 $23.37
GRAD1140 FE, 9 101.000.425.000 X15.00
DEVE0PERlMPACT YEE $X405.000
ARTIN PUBTAC PLACES - 1w 270-000-445-000.✓J
1)
D '. 3 S LTC"1'iO1�1 AND PL AW CYIEC'K
$4,324.90
D1SS PRE-PAIDRI- a
$0.00
SEP 26 2003 1.
1TMWffFW* DUO. NOW
$4=430
CIFATA
NCE DE T
=
RECEIPT
DATE
Gf
BYFINA j D INS ECTOR
�/
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
A
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
L I
Combustion Air
Roof Deck✓
O.K. to Wrap
✓
Exhaust Fans IV
F.A.U.
Framing
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls Alzy
Party Wall Insulation
Condensate Lines
Party Wall Firewall
42
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROV _
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
PLUMBINGPPROVA
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:
Final
Utility Notice (Gas)
ELECTRICAL PPRO ALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures /
—
Main Service
_—
Sub Panels
_
Exterior Receptacles
G.F.I.
Smoke Detectors X.
Temp. Use of Power
0-1
Final
Utility Notice (Perm)