0111-064 (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.
Licensee #. " Lic. Class Exp. Date/n[
Signature of Contractor
OWNER -BUILDER DECLARATION
1. 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 ownerof 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
/o /-i 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
eection 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 PAC)FIC SMP1OY11F." Policy No. •itd1,W1' C4,303019
(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 forthwith comply with those provisions/
,Date: ? - ��`^� Applicant 7 f
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 sbit
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 D
I Any.permit issued as a result of this application becomes, null and void
work.is not commenced within 180 days from date of issuance of, s
permit, or cessation of work for 180 days will subject permit to cancellatio .
I certify that I have read this application and state that the above information
correct. I agree to comply with all Cityfand State laws relating to the buildin
construction, and hereby authorize'�epresentatives of this City to enter up
the above-mentioned property
,ffor I- ispection purposes. ;
Signature (Owner/Agent) /-! Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
234, '
b
JOB SITE` `Py
APN
_
ADDRESS 'i y,��y,
X31 �� Trt��,.� %�
OWNER
CONTRACTOR/DESIGNER/EN INEER
K)LIARROIXTIMIRS MCI,
TOT 1, P(Ra 111 MIS TWO
74 -9.23 X10VMX Id -OR EAST U1C7 TE72-220
74- 3 130va; ( i Nm x.,,An swT'is-id7.2o
P.x :0 X !' CA 922460
PALM MSERT C4.0% 92260
(760>04-909 3832
USE OF PERMIT
u 01.,OT e34° SANTA. MOSA-,A. PKRIALT DOES NOT INCLUDE, BWCK
75% FLAN CHE .`'K RY
k.1:ix,.trw"1'ION FOR. ViU:UHPLZ? ISSIUJt ICE OF UA 1 E PLAN "TYPZ
CUSTOM, C!OHSTRUCTION %74'LE10 € Y
PC' RCIV1aN1110 .32A_00 s1r
aARAGE4CARPORT 736,00 8F
EY.M"72110 COST OF CONYMAX. nom
31 01'' M 79 '
PRR'1 V.1'12 SUMMARY
CON9,"fRUCT WeNRKE, 101=100-4,18-000 $1370,00
PLAN V..MCK 11ME 101-000-43.9-318
r.AZ,OWRIci LM, 101-.060.421-000 $98.50
01-000-4 20-000 $I1 i9.55
PLUMP.)MI:O FER 101-000-419.000 �18fI,�D
: NO mCYnoN Ft 121- RESID 101 -ow -v. 1 _alai 1151,06
eM;;.> DRIO PML 101. -000-42;340101t)
A= 1N F118 .,1T:' ,P &0*M, - ltM1:.'a7TSv000.445.000 WOO
S��y�}��� ��!! rysn-r �+�/�,+�,yy- 5�{yv �,q p q{yq^yy may/ 3^-'+ y
i,d.[7"'1okd'l.t... C(5V 93`ICD�1s.�.A2�e.[%'�.i�'6.k`'�;'B.4d!r •S-: .E@ C.c..t�J(J.i`w
dpi] j�'
�%'+�°3'�'�'r•,6 0
4 ;1 F09 PR's'-PALD RM
e v TMA:Y0,13 S.rd:11Y.6U MES 2a!TIPPO Vi''
ep�$0,00
19'YJa7A+�:tN -
KC 0 3 2001
CIYY OF LA tint!
TEONMY—= `r' °
D
!e' 3 {�I'
BY
DATE INAL D
oZ
INSP CT R
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Forms & Footings p��
r
_
%
Underground Ducts
Ducts
Slab Grade
�� IJp'f�
Return Air
Steel
Combustion Air
Roof Deck
O.K. to Wrap
' �
0
Exhaust Fans
F.A.U.
Framing
- ��
_
Compressor
Insulation
_� dy
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
�Tlb2
Final
POOLS - SPAS
BLOCKWALL APPROVA S
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
/�.`�lI/�/
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral /
Sewer Connection ��/�%�p d
/%���/�
Pool Cover
Encapsulation
Gas Piping
Gas Test
)
Appliances
Final
COMMENTS:
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
i
Final
Utility Notice (Perm)
Certificate
of Occupancy
Cityof La
Quinta
Building --an d Safety Department ti .
/� OF TN
This Certificate issued pursuant to the requirements of Section .109 of the Uniform Bui/din Cod
certifying that, at the time of issuance, g e'
this structure was in comp/lance with the various ordinances-
, of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 81-575 TIBURON DRIVE
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0111-064
Occupancy Group: R-3 - Type of Construction: VN Land Use Zone: RL
Owner of Building: TOLL BROTHERS INC Address: 74-923 HOVELY LANE EAST STE 2-220
City: PALM DESERT, CA., 92260
By: DANIEL P. CRAWFORD JR.
Date: 7/18/02
Building Official
POST IN A CONSPICUOUS PLACE