0302-042 (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
177 16951 B 480103
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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). . .
O 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.
�() 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
permjt is issued. My workers' compensation insurance carrier & policy no. are:
Carrier LIHRTY .MUT43 AL Y Policy No. WA262D0114723D12T1
(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
Code, I shall fo�hwith comply with tho11.
se prIsio fs.
pale: A Iicant, fI'
Warning: Failure to secure Workers' Co ensation 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 Geode, 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., l 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. "
S t Owner/A ent)lrr.�,4.».,.w Date
�, Igna ure ( g •
BUILDING PERMIT PERMIT
- V t9r1
DATE VALUATION d,.y�t,�r�a. LOT r�;,'j TRACT
.�,�
ADDRESS \ •30^. 7xmkNo wil VaG_'r. JOB SITE
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TOLL BROTIM8 We
TONJAMZ01ralms WC
-773-123 PRED��,�Aiwily G 0.100
�y�1� �� X16.10
PALM A.=�,:6S3,i: �ii F. CA (42260
T1,a3-�1y%,�iY.'��.�'k•"��.yu.)
q �q.
1C`AL+I DIStrL'R C:,r'1, ii2260
a 1601674-9699 C5 +€�32.
USE OFPERMIT
�J.
M RW:I.E.LAM-Y DV•Y2��...1.WYtlO
S
S PV - LOT 71, 8-MIZE = A. PtP,RFe )l WDES RIOT INCLUrie, P001,,, SPA
13WX �rA1. L0 OR. DRK W AY APPRO.ACK 7 MAN CF FWK FUR
0.33UTION 3" UE TO MULTIPLE ISSU A14CE OF S.A>IAB PLAN TYPE
Ct1;3TWO WNST RUCTION 3.047,00 3F
PORC10PA IO '31:3.00 51?'
�.'�.L`adA COS'I�.� OF CO3.i SID. 1't'yM00
'x,774.2,0
7�
i�P,���%i�. ,i. NIM SUMMARY
CON TRUCTION f�LF, 101-000-4184=
PLANCHECK PEI. 101-OV0,439-318 $W.�7
M1� NICAL ne 101.000.411.000 $/ %co
ZLZC'rP,IC AL PER 101-•1'10`( ,20-000 sm.1.5
PLUMB11,00 Trym 103 -{ O-41 MOO $203,25.
S'1'�,CyW0 PdlCDTf01d FEE. RES10 101 -.fly 1.000 $25,39
OUDINO K9 1 tai m000 000 215.00
Q� �L.APER IMPACT Pfl�Lg S_;40swo
.
ART rpt T°tbl LI(.11'LACES - mir 270.000.445.300 W4,44
°fiUB-7.'O1AL t ON933",WdfL'�i`ifald A= PLAN CTC
$4, 850.59
IMS PRE -PAID S�WO
t�' .00
r_ ..,.
x
2 0 1003
CITY Or U. . �461'NTA
FlNAHCE DEPT. �G
RECEIPT
DATE
BY T FINA D
SPECall
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
. p -j
Exhaust Fans
O.K. to Wrap.
v
F.A.U.
Framing
_
3
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
Av
��--
POOLS - SPAS
BLOCKWALL APPROVAL , -j-,--
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
_ p cj'�
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
�i
Utility Notice (Gas)
__
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service � —
Sub Panels
Exterior Receptacles
_
d
G.F.I.
— —
Smoke Detectors
ZZ
Temp. Use of Power
_
Final
Utility Notice (Perm)