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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 D' 4131/101
-Date Sr ` "—� Signature of Contractors r G``'
IV
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 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.
SeZ )' I have and will maintaih.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 lr3is .' ''" MUTUAL f% Policy No. 'iF A2i2 04 'oy0,1;2T+:
(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 sgall forthwith comply with os�e�pr� 'isigns.
Date: 4S 4Y Applicant . „o!'.n"')
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 asa 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 inspe tion purposes.
Signature (Owner/Agent)O/, � ! -�'s" '"' p Dater /-t
PERMIT #
BUILDING PERMIT
030s,"191
DATE �rlfim VALUATION mop rY*.i. s` LOT 162 TRACT 103, 1
JOB SITE
ADDRESS �-.�'35FY,.' GRADOJ.�RI ES:
�
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
TOLL LAR(AiWM4 31-K!
TOU".0"ROMSR I's MCI
73 - Ut 1 TPRE = WA R11,'C, S>t 1 M
7:;-121 FIRIDIYARING0100
RALM ;A;3ZXr CA 92260
PALM DF22TRIT CA. 92260
('760)674-9695 CBL#° 31332
USE OF PERMIT
,1lrl J « Lit' 10S, jNQ A lvi tiusea• iSd,1.4.St
POOL, VPS Oft l:1?l.151ai>'�'AY APPROACH
f'ss lr3i►4 Cru tva'fltJ{"� �� 3,m/.00 So
RCiVPA 10 t6i.00 SN
752.00 3F
FIXTrI ,Ir. P'Fti0 COx"v'1" OF C0110,'RM1110K
112,1,A;1.Zo
SUMMARY
C;ii%TwT:'td.`>'tr'<• OX FUR X5.11 -,0U0-4 YC -000 'SVI610
P i 9 C&HIIXIif wlt 1.01-t1Uh-4 .9-3111 V,149.23
byICO:ut'�X. A11—iC:.��.LFF'E 1iii-/O�,N:,�0-C,/I�•tni00 3M13M
a:d.h�C l RA_,. ,L d'FY. - 101 -IM -420-000 $*03.69
$
1�A.L73 1.; AYr t 'AM 1 U'1-000.419-000 RF 00.00
�'1 �`�;.�1f E:��°'O�t :I�f; « re;�::� ::4 � ^f•1t�-r�s$1 �Q(�t3 v3�.19
t31fA� lA' Hsp:) . i; y .-M.), ',.3.000 11 E".(>0
IMPACT 7X21#
ART 114 1''M.5C k't.. A09S PKIIr 270,000,445-000 $304,70
..;UBI-TtJsrr.Al.+,.OW"''It«_f4ii4_. Mom iw�X"LA1`9 i...�'Zl:.c.I ,F[
d+��r�V�i•�1 ,
M193 M-11"Am FEE P,
P�iAY 2 J 1003 j
rInJAV ,, mfiE
RECEIPT
DATE
! ! ;7�
BY
A, "�' - 1
DA IN
I PECTO
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0 ;H'
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set BacksUnderground
Ducts
zq
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
Framing
✓
F.A.U.
Compressor
/A)
Insulation
,i
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. lath
/
Final
—_
� J '
Final
BLOCKWALL APPRO ALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVAGas
Test
Electric Final
Waste Lines
Heater Final
Water Piping
v
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
A
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL A PROVA
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles 10
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: