0403-360 (SFD)LICENSED CONTRACTOR DECLARATION
1. hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
', N W Professionals Code, and my License is in full force and effect.
�.� cr) License# Lic. Class Exp. Date
r- w LO 777699 B 4130,104
Zt-- Date Signature of Contractor '�� ��G(✓°? C ,'q ".
(D O.�i
J U C:) OWNER -BUILDER DECLARATION
HLU r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Cn License Law for the following reason:
Z ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
O0)
a Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W�= compensation, as provided for by Section 3700 of the Labor Code, for the
m. J Q performance of the work for which this permit is issued.
Q U 1 have and will maintain workers' compensation insurance, as required by
d (-) Q S ection 3700 of the Labor Code, for the performance of the work for which this
cl: LOZ permit iu�s�syed tMy�4wo�Jc�ejs�c�ompensation insurance ca�r�&�poliQoo.lppe
It Carrier Policy No.
cb 5 '
O
J (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
1 subject to the workers' compensation provisions of Section 3700 of the Labor
•`•77 Code; l s dll forthwith comply with thh�se ov Ins.
Date: ��L�r,�% Applicant-//,��!'+s/✓rn�a,-.-,�
• �1'0' 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
�1 any permit issued as a result of this'applicaton agrees to, & shall, indemnify
(�v�p & 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 V_ ���
t
BUILDING PERMIT PERMI04W 04WS-360
DATEVALUATION $36.3,687A0LOT 193 TRACT 3134.39) �-
r�. 41
JOB SITE 51-025 YL I• URADO D RI1f
APN 772-270-001
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
`MLL DROMEFa WC
TOU BR&HERW WO
P3-121 PRED "WkPJNCT 0.3 00
:13.121 FRS WARING 9100
PALM Duman, CIA 92260
PALM DESERT 12A 92 260
(760)(174.9699 (M-SLO 383;
USE ,OPEMI !, FJEY«.i' ;�i3ykJ' LLE
RIM .-,fA:+7YA'IhJf%.A1A11&.,iv P1T..49MVr 61r)PVlJn
IMP1,111P.1X1C°. "'
WAL14 POOL, S'PAOR DRWEA+PAPPROACH, ,
CUSTOM S" v'N aTRUC f'IC-114 4,37.1.00 SF
PORCIVRa TIO 650.00 1137
GARAcz?rR.A,RPORT 1a.06 Nle
Rn6Y� �WAXED COS!�'f OF CONS1 WL..nO
CC'13OTRUCT1014 F U 1€11.000-41 S-000 51,543:50
PLKN C HEICK i?h e- 1014000-439-318 $1,26.3.43
MEC11AMC.PAIME 101--000-421.000 5136.50
BUIC'A RICAL !EY 101-00"20-0010 $2003.09
PL.EF10THO +ELt 101.000.419.00101 S21MIC
S:I'RM10 2%10T1ON7ZL .ID 101.0'00-241-1:00 521, 7
ORAD1140 YZE I tV 1100.423- 00 $15.00
ART Ela PUbL,1C PLACES - R.MIt 7.'70•000-W-000
suB-TurAL CC5w=Lit:1 ax AND in. ex
�rtS,2H9.'E,3
n n LESS PTRE--P.AW VX0;
:fie 100
APR o 2 2004
CITY O� LA QU1NTA
F!?dANCE DEPT.
RECEIPT
DATE
t
BY
DATE FINALED
INSPECTOR
3911
,
�Ua!
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
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
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
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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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 B 0413012.
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).
( ) 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:
Carver L3F EWE .MUTUAL F" Policy No. WA261D0C14n3012T1
(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: ADDlicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes..
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE0411y2a c VALUATION �,�►€ 7AO LOT 19� / . TRACT 3,� 349
ADDRESS 51`015 IM .DOIZADO DRI.VC JOB SITE
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TOM BRO77MO :Ll`1C
TOM BROT .R:9 INC
73.121 FTS WA '(WQ A] 00
73-121 FIRM V>rA"0 6100
Z AIMDESTRT CA 92260
PAI14D09E :T CA 92260
(760)674.961.19 CMA 3832
USE OF PERMIT
SSid'CI'iR :�AMl:LY` 1;J�i?'F.,,f J�dC.3
S.PD - VKUTANA.A/41cosit�a. I?ZRMI T ClO?-'?, NOT INCLUDE BLOCK
WA"' F10OIh PPA OR DRIVEAV APP;RO.ACH,
OU19701,$ CONSTRUCTION 4,3114,00 SF
PORCHIPATIO X530.00 Say
S°#A,RAMC'ARPORT 730.00 rF
1CS11MIXE ;U CGv s' OZ, CONFDRUMON
363,M7.60
:Ei3`� � - r FF.r su.NwAR Y
COMIRUC'TION FFR 101-000.418.000 51,563.,50
PLAN C1IECK IrEE 101-000-439-318 $3,261.45
h+1W HANIC'.A L lea, 101-000-421 -OOU $154.0
ZLIP,f` T ICAI, r &F, 101-000-420-000 $208.69
PLX?MBINO .FEE 101.000-419.000 $213.00
ST RL:NG MOTION IZZ - RES11 D 101-000-241-000 X36.37
O' 12.ADING FF E 101.000.423.000 113.00
I'1EV—V OVER IMPACT .FEE $2,40.51W
ART YN PUBLIC PLACES - RE„SIE 270.000.445-000 1409.32
STM-TOTA1: CONTMUC11011 AND PL AM C f_vX
LESS PRE. -PAW FEM
$03.00
,tO"i Ale P R�?1 :H' 8 D(fr N'C1'V4`
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVAL
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Qucts
Slab Grade
_
Return Air
Steel
_ _
Combustion Air
Roof Deck
_
Exhaust Fans
O.K. to Wrap
�p
F.A.U.
Framing
_
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
Final
BLOCKWALL APPROVALS
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
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
Q
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
Final
Utility Notice (Perm)
COMMENTS: