0302-194 (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 4/3O103
Date ~� Signature of Contractor,, —.dir�.ak :�....,r
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
Codej. I '
( ) 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.
\j(a) 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 1,,1B'ERTY MUTUAL TUAL Y' Policy No. ` A2621100473D12 A T
(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 /shIIfrthwith comply with those provisions.
gate: , Applicant %Y �.•
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is mader& each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if r
work is not commenced within 180 days from date of issuance of such L
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree.to comply.with all City, and State laws relating to the building
construction,- and herebyauthorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. r.
Signature (Owner/Agent)<i�+J�. J�Sd�t•—• Date'
�11,
PERMIT #
"'BUILDING PERMIT,�,L_
DATE VALUATIONhr i .p LOT 7 TRACT r i,
W.w.�J f:$uwry •I• o�5!ad
JOB SITE
ADDRESS W-2" VIA V •AMMOSA
OWNER
CONTRACTOR/DESIGNER/ENGINEER
rOLUMMIMRS 190
TOLL 1 .0°l11CRS INC,
73-121 IFIRTM WILRM #1.00
y -121 "RED W.Amo 0.100
PA1.1w. DUM CA 92260
:€'ALMD1,?,1,JM.?'T ]�A, 9,2260
(760)614,-9699 Myaff 383:
USE OF PERMIT
SILO • :.OT 4�.•�'SFf3C9HAv.:. PERMIT DOES NOT INCLUDE BLOCK
XNA.1..c. , P 0 01,, .1PA. 0R. D R I V IF,WAY APPt20ACtf'
CO3TOM CONSTRUCTION 2,8,00,03 q
t'. �AR0,LOWCARPOiR 61,0100 001,
.
S,'.& 0091:1 OF i.".ais-;iEk1dMON
23.3,1M.50
�y �p y�� ywp� �yy��• � gRIS
l`.. -'t NOTRLt.CT10141""fT.,J!+• 1O1 -000.4`1S --too $110SPAD
PLAN �A:•iiikCK' �'pt;YE 101-pOY�00-4:39,93,1�f€;; ��.+iA�`,�t OO,
.Y3i!r`%n'1Xf WICA1, FEE 101-OOG.-�Q�2 il'-0 V• .NP t. 11„747
Fe,FICT.R1CA1< ?& 101-000-X320.000 $1j65.30
PLUMBEINO FEE 101w000.41'P-00€1 stU N
S7'12r;J' O MOTION til E • RF`310 101,000-2-41-000 $23:37
OR4011,1r;1PER 101 n000-423-000 115,00
TJWFADPE.6i ttkPAC1, MIP 3:�o.5.700
ARI` IN Altx1.3MAC PLAC1"..S - Rig RIE 27"00-445-000 00-445-000 scot 33
9U -70 f. AT, COKU a,�`�c UCN701.A, ID's+LANN MI CE
TZ93 'YRE^PAID REM
$0.0)
LMAR 076 1003
CITY OF LA QUINTA
DE TE I
BY TE I ALE O
SPECTO
tt
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
,p
Ducts
Slab Grade
3
Return Air
Steel
Combustion Air _
Roof Deck
el. .O r
Exhaust Fans
O.K to Wrap
_ _/� _A.
A.U. I/
Framing
ompressor
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
. (j
—d `
Final
POOLS - SPAS
BLOCKWALL APPROVArL
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
_�p�0 3
Heater Final
Water Piping�j
_ _
`✓
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
• p_40
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
.� 2
ELECTRICAL AROVALS
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)
rrYi 7'