0211-084 (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 4130103
Date Signature of Contractoy%,
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-insurefor 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 LIBERTY muTiw, F: Policy No. WA2621*0471-Al Wf
(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 shao. h
I fwith comply with those paovisioR's.
-.Date2 Applicant/ ,il, — —
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 restric`tions,•set forth ore, 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. I
-Signature,-(Owner/Agent),5r,/ f� FGA � " Date _
aI
BUILDING PERMIT PERMIT /J
DATE
VALUATION TeY0 LOT —.7 — TRACTJOB
aa
SITE
ADDRESS PI�—�.1._Ffum i e e C �fe
APN 772450-007
OWNER
CONTRACTOR / DESIGNER / ENGINEER
'1't3LL M01I R SIM
TOLL D.IZ,a7MW INC
73.12) r1,�'.�WARM0 100
73-121 TREED WARWOr0.)00
tdzaii)6i4.969 M4 `.3832
USE OF PERMIT
8DIGL'I"s PA11 .-Y DWELLING C
'" � _ • -
'+SFD n LOT ,Efk, V9,N;'AN,'A -A. FER.MIT I]tQES Nt3' ,1NC:L U10J?, 33LOCIC
WA" P00. SPA c R .DRITI::WAV APPRI>ACH -
MWONi CONSTRUCTION 41057.00 2F
,
PORC:i'Ii,'P.ATIO 314,00 SF
Ufs'.kD"M CY.`)tur OF C:(FINSTIM117off
336, 71.440
CCiNSTT3.UC-7i0N ITEM 1.01-000-91181-000 S1A69100
YL..AW CHECK Fp's 201.000-4:sIS !7.,187.05
WCHAHTCAI. FES 101.000.421.300 M43,50
L£.Xtr' rdC*:R L PF%r 1: 01-000-4204*0
1''i;UMBINO FEE 101-000419-000
STSCONO M.0T1rJN FIEF — RZ.7�1D 101-000-241-000 $33.67
c RARING FF% 101.000.42i-13.00 $1100
`'DAZVZL,UP1!P IMPACT PK.V $$405,0.0
ARTIN PUBLIC PLACES - R€ ME 270.000-445.000 041.131
} r
..TMI./,�.kLtvD'�...kQe,ITCY,"�r���.
�i�'�tlt0.'i�i.�'C�
:feta 4 � P.M.1'AW F1173
6D , 31�3
$0,00
.
3 a lAs�
-
5�i" 1n Y�;+ IDUE,NOW
C] 1,t3� 0 '+i .t 19 I— 1 . M,tt•,x�.�S ID `UE, 27.�%9'Y
� ter
tsly"Zc; �
NoY
OF
CITY NCE OF PT.
� FINP� �.
RECEIPT
DATE
I
BY
E FIN f
IN ECTOR
- - - - - -
ti ;7
?-lI
wr,
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
i
O.K. to Wrap
D S
F.A.U.
Framing,
../ p
Compressor
Insulation
•v 3 '�
Vents
10
Fireplace P.L.
Grills
_
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
.o ?
Drywall - Int. Lath
_
/�
Final
Final
JV _
_
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Waste Lines
/
Electric Final
ater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
�l0 ® a..-
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
.r
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service ✓ d
Sub Panels
Exterior Receptacles
K
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)