0211-096 (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 4/30/03
"Date o1 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).
( ) .l, as ownersof the property, am exclusively contractingwith licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). L1
( ) lam exemptvnder. 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. "n'
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 MUTUAL F Policy No. _ RA,,,
(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 prove ions.
date: - Applicant ""7
, --- -�
r
161/
Warning: Failure to secure Workers' Com ensation 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__? ;
1. Each person uponxtioesbehalf this application is made & each person at
whose request and for°whose benefit work is performed under or pursuant to
any permit issu-ed 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 fort' 80 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
t
BUILDING PERMIT y PERMITq
^ 4
-
DATE VALUATION ,z,,* � LOT TRACT man j
JOB SITE ADDRESS U e xun+ rtc�� fAtl `�
APN 772-2:1.-4.1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
TOLL 1ARCM-MRS ]MCI -
INC
73-120RXEDWARN43- 9100
73=1"IV II 'AItif'ARING0?00
PALM OO CA 92260
PAaIMD&SURT 0, 922'6U
(760,674. 9699 OSLO 38332
USE OF PERMIT
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SID • .LOf 4,% BZUZ , •A P:&sZ'MIT 0093110T 1Ntw1..UOF, BWCX.
P004 PPA OR DRIVEWAY APPR(ANCK
(%Wyokd CONSTPUCTLYN / ,o,'04700- S" ���
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FORC;1'4BPA710 �'a13.00 SF
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MRSMWIMARY
CONS -'RUCTION 1�� 101,,000-418.000 $1121%.00
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;Cs _Q4 CHECK FEW R 1Ir(i013-�i�9-� F3 $�S 9�i
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GEADINO FU1 t3..%izt7u4 3�0070 3 .00
l:�LP"J YL,0PP,P2. IMP,AcT "ism �,2,k0;Att0
ARTM M AUBLIC PLA.C;_' - ROTE M -000-i45.000 St31, F�
SUB-TOTALt �3�T�"%,Fi:Ltt,�, ,014 AWL) PLOT CIM
$:5,27C.•43
LB03 PRE -PAID MES
$0100
F. AGA NDUE
ov
CITY OF LA QUIN:a-
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RECEI T T g• BY n
D I. INSPECTO
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
10
Exhaust Fans
O.K. to Wrap
. . o
F.A.U.
Framing
Insulation
_
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
do
Exterior Lath
L{ • _ p 7
Drywall - Int. Lath
. p ?j MT
/01
r
Final
_
Final _ -
BLOCKWALL dPROVALS
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 APPRnVALS
_ 9
Waste Lines G
Gas Test
Electric Final
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) l�
ELECTRICAL PpROVALS
C MMENTS:
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service �(f
Sub Panels _
Exterior Receptacles 0o,/
G.F.I.
Smoke Detectors
Temp. Use of Power
Final ✓�
Utility Notice (Perm)