0210-206 (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
777699 B
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:.
Carrier )AREM t1 UTUAL F Policy No. . 'W",'2 8D4'n3+4 J2TY'
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that iri 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 sh II forthwith comply with those provisions.
Date:.. v ` Applicant All /.
lf op
Warning: Failure to secure Workers' Com nsation 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. y d°
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, Indemriify
& 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 I
work is not commenced within 180 days from date of issuance ch
permit, or cessation of work for 180 days will subject permit to canc n.
T
I certify that I have read this application and state that the above informn is f
correct. I agree to comply'with all City, and State laws relating toathe dig l
construction, and hereby authorize representatives of this City to ent .up n
the above-mentioned property for inspection purposes. f CI
Signature (Owner/Agent),"M� +k! l� . �r � Date w .
BUILDING PERMIT PERMIT”
DATE VALUATION @@nr LOT' TRACT
Jlo�.b'9g�'�w7h
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JOB SITE--•-^^pq,,,,+,,���
ADDRES � ��Jw 57";_ $ fEc4,ZwSAa.,2W4X*7
APN
OWNER
CONTRACTOR/ / EN (NEER
IrV 'BROtIMU111 WC:
TOLL :E3:1z.C:5rklyaS INC ;
74-9.7315(0%.x` L141415 -MErf STYY172-720
74-923
PALMDi+.ta','t~RT CA 92260
;C=ALMDFUM:Z C A 9'."260
USE OF PERMIT
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WCHAAICAL FrM A01-000-421-000 S.150100
A,".qi';C`ttYa2yTc AL�E�pf�%f 101-000-4204000 $IM.50
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1.01-000419-000
PlAJi'�IorHo FEW, 1 1.07.--000^••�DJ.9•�000 N.I90A
MONO M071Gn FEE a .itli,, 10 101-00( 4411 ••0% $3143
0RAD1140 FEE, $1.6.00
DEVELOPER ItAP.ACT FK!? s; -w.09
ART Ili T:1 BLICI''1. C<M •, USK `�7C:-00040-000 133101',4'3
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CT X3.1 2002 u�
rY OF LA 01-IINTA
f �E DEPT. -
DATE
Y •
t�
DA NAL
INS ECTO
INSPECTION -RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum Air
Steel
_
Combustion Air
_
Roof Deck
Exhaust Fans
O.K. to Wrap3
F.A.U.
Framing
-0 3,
Compressor
Insulation
w 3 7
Vents
Fireplace P.L.
Grills
_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
/
Party Wall Firewall
Exterior Lath
Drywall - Int. lath
G
Final
f V—
Final+
�%
V
POOLS - SPAS
BLOCK
F L AiFP ROVAL
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 R VALS
Gas Test
_
Electric Final
Waste Lines
2
Heater Final
Water Piping
IrPlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
aZ • o ?'
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) _a, V
ELECTRICAL
APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
'►)�
Main Service
_ _
r__j
Sub Panels
Exterior Receptacles/
G.F.I.
(/
Smoke Detectors
Temp. Use Power
r
of
�O
Final
Utility Notice (Perm)