0304-397 (SFD)LICENSED CONTRACTOR DECLARATION
C/) I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
I, N W Professionals Code, and my License is in full force and effect.
M License # Lic. Class Exp. Date
777699 B 4/30/03
rZ
oZ r� Date Signature of Contractor
0O
F-tp OWNER -BUILDER DECLARATION
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ U) 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
a sale (Sec. 7044, Business & Professionals rnrla)
( ) I, as owner of the property, am exclusively contracting with licensed
# contractors to construct the project (Sec. 7044, Business & Professionals
Code
( N() I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
rn
a<
WORKER'S COMPENSATION DECLARATION
C) 2 1 hereby affirm under penalty of perjury one of the following declarations:
0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X w LIL compensation, as provided for by Section 3700 of the Labor Code, for the
le 00 � Q performance of the work for which this permit, is issued.
co Q () ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d
U -)
Z permit is issued. My workers' compensation insurance carrier &ppolicy no. are:
Carrier LIBERTY MUTUAL F Policy No. WA262D004723012TI
ao O
P Iw g (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: Applicant
N
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
a addition to the cost of compensation, damages as provided for in Section 3706
z of the Labor Code, interest and attorney's fees.
G
Z 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.
r �• 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
PERMIT #
BUILDING PERMIT 0304-397
DATE VALUATION $219,963.60 LOT III TRACT 30357
JOB SITE
ADDRESS 80-550 VIA TERRACINA
OWNER
TOLL BROTHERS INC
73-121 FRED WARING #100
PALM DESERT CA 92260
ucc or rcnmuT
SINGLE FAMILY DAVELL NG
Jr 1J - L,V 1 111, L,.eUV111VA-K. rr r,9W1 I LJVCJ INU I ,
WALLS, POOL, SPA OR DRIVEWAY APPROACH,
APN 772-250-011
/ DESIGNER /
TOLL BROTHERS INC
73-121 FRED WARING#100
PALM DESERT CA 92260
(760)674.9699 CBL# 3832
CUSTOM CONSTRUCTION 2,631,00 SF
PORCH/PATIO 399.00 SF
GARAGE/CARPORT 495.00 SF
ESITMATED COST OF CONSTRUCTION
PERMIT FEE SUAUvIARY
CONSTRUCTION FEE
101.000-418-000
$1,059.50
PLAN CHECK FEE
101-000-439-318
$874.17
MECHANICAL FEE
101-000.421-000
$124.50
ELECTRICAL FEE
101-000-420-000
$157.99
PLUMBING FEE
101.000-419-000
$184,00
STRONG MOTION FEE - RESID
101-000-241-000
$22.00
GRADING FEE
101.000.423-000
$15.00
DEVELOPER IMPACT FEE
$2,405.00
ART IN PUBLIC PLACES - RESII 270.000-445-000
$49,91
RECEIPT
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
LESS PRE -PAID IF -EY -43.
DATE
TOTAL PER= FEES DUE NOW
BY
DATE FINALED I INSPECTOR
219,963.!
$4,892.07
$0,00
$4,892.07