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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
9 B 0e, 4/30104
Date 3 ° a
of 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
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
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
LIBERTY MUTUAL 7 WA202O0047"x3012'FL
(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 Jorthwith comply witht os p is oras.
Date a � ° V Applicant Q C-410
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)
// fes"+ �,GJ�✓f�--�---- Date �y <Y .
_ V a,tit
BUILDING PERMIT PERMIT#
DATE / VALUATION LOT €1�402•-2S TRACT
V' '/
/J 174 30357
JOB SITE
APN
ADDRESS
5044511, DOR"O DI2ME
772-250-011.
OWNER
CONTRACTOR/ DESIGNER / EN INEER
.-.
TOLT. 43RC AMPIG RRC
TOLL 33ROTl:WS, WC
'73-121 F1 WAn4G-A]X10
73.121 I-1i"DWARM Q,Y100
LA+[ D.&SER.T CPL 92260
RALM DIFZEW CA 92260
(76.0)6'?4-9699 CB1.0 3832
USE OF PERMIT •
SWOLL 1:,! k LY DVIF (3
SFD • LD T 174, MIU MON T1, -PEi€MJ T OOt> NC T IiNGVIDE U1.4.=
WALLS,, P004 SPA OR.DRIV•IMAY..?41':'ltOACI'1.
CUSTOM CONSTRUCTION-%847.0LD ; F
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i3C3C:IfP�'i'i 40 S61.Gi1 SF'
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E'S"Il tit61 rTM COST OP CO.I*Sfa`M1vIMON
a214MA.,i3U
CONSTRUCTI0N FLEE ) 01.000.418.000 $1,416.50
PLAIN CHECK FEE 101 -00049 -?18 $1,140.4
MECHANICAL FEE $150100
s,I EC'Pi71CAL FF -E 101-000-420.000 $I205.64
Z
PIsU1R4I} NO FEE 101-'•700-419.000 $100,00
W7'RO'NO A90"d'HYN FRE • R2SID- 1014000-2.41-0100 $32.15
f3RADI`NO FEE 101-000-423.000 $15,00
►
DEVELOPER IMPACT FEE $2,405.00
ART W PIJH•LK PLACES - RE'.SIi 770-000,445-000 3904.'70
;15.713 -TOTAL CO CIMCK
$5,868.10
f l �35 -PRE-PAI1`� :rWETS
$0.00
G
0
MAR 4 204
CITY OF LA QUtNTA
FINANCE DEPT.
RECEIPT
DATE /
BY
DATE FINALED
I SP OR
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
Set Backs All._
Forms & Footings _
Slab Grade
MECHANICAL APPROVALS
Underground Ducts _
Ducts_
Return Air
Steel
Combustion Air
_ _ _
Roof Deck _ _
O.K. to Wrap
Exhaust Fans
F. U.
Framing '+QIli,_
ompressor
_
Insulation
Jents
_ _ _
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APP OVA \
Gas Test
Electric Final
Waste Lines
eater 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 APPROVALS
Temp. Power Pole 01_
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)