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0308-105 (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? l301/2t DateSignature of Contractol'�"%T""'""" 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. (X) 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 LIBL.ItTY 1v UT'U;AL F.' Policy No. WA262=14723012Tf (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 sh 11 forthwith comply with those, pro islo s. Die: 91044Applicant, ° �ds�s-.-"" 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 Js 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 made & each person at whose request and for whose benefit work is performed under or pursuant any permit issued as a result of this applicaton agrees to, & shall, indemni D & hold harmless the City of La Quinta, its officers, agents and employee 2. Any permit -issued as a result of this application becomes null and void work is not commenced within 180 days from date of issuance of su permit, or cessation of work for 180 days will subject permit to cancellatio . I certify that I have read this application and state that the above information s correct. I agree to comply with all City, and State laws relating to the buildi g construction, and hereby authorize representatives of this City to enter up the above-mentioned property for inspection purposes. Signature (Owner/Agent) 40 4d"'"""` Date, BUILDING PERMIT PERMIT# UATION ' LOT 11.1 TRACT DATE r VALUATION , S0 30357 JOB SITE ADDRESS 1�1- ' Y.Ii� _ryQa�i APN 77-0-0E i OWNER CONTRACTOR / DESIGNER / EN (NEER TOLL BR.CAH S rac "rots, F,R 011MRS INC 73-121 VRM) WAWNC #'100 73-121 F :L'► WAXW03 41 00 PALL64 DEMRT CA 92260 PALM DUM CA 92260 �a�fJ,�a7d��6:� C„�1I:�1 31333 USE OF PERMIT 31.N IX. IVAMY DW&LING sfr'Z:! • LOT I I I, ST-PD012A-A. PFRMIT DOZS NOT INCLUDESUDCK 'WAIJ,S, .7^001., SPA Oft DRIVEWAY APPROACH.. 75% Rt DUCTION 1r0 PIzP�1d CRECK FEDI DUE,O MULTIPLE ISS7,14NCE OF SAME PLAN TYPE CUSTOM CONSTRUCTION 2,300.00 OF 7?OACIVPA110 r7s.00 3F CtARA.siLIVARPORT 610,00 By 010"n,hL4TED COST Off' E ownR1;ICnow 233,1a.3 FE'RMIT li'EE SL7MMEARY CONS'7WOC;T10 41 301-000-418.000 PLAN CHECK M., 10+1-0110-439-sI8 $%Xy.00 1►H,Ei'k3,iNIC,2LLPC'r 101-000-421-000 SI11.50 FA,W,TRiC'AL PIZ 101-000-120-000. $1&6.©0 PLUYzf BINC3 FE . 101-000-419•000 $194.00 ST;.ZON.0 MOTION FEE _ RLISID 101-Of/0-241-0'00 otZi ,? ORAC?INGME i4t-0004"V-000 S115.00 DEVELOPER IMPACT FE -3 $$4805.00 ART IN PUBUC i'LACM, - ROSM 27c0.000-445-000 $844.33 SUB-)1•0i.Al, f,WOMs7:LL{.iICTI.Jif AND 2'.4AY C$7XF, $4;324,90 L1?Pi Ir • ;3tl, 00 ".l OTAL n".[�4+I�' -rip. r D �C� 4N $4,324,". SEP 26 2003 CITY OF LA FINANCE DEPT. DEPT. " RECEIPT DATE r BY D E TO INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade k&7 Return Air Steel Combustion Air Roof Deck ' / Exhaust Fans O.K to Wrap ✓ F.A.U. Framing Compressor 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 Final / POOLS - SPAS BLOCKWALL APPROVAL 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 ,i 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 COMMENTS: - Final Utility Notice (Gas) ELECTRICAL APPROV LS Temp: Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service I AV A Aid Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power 01 Final Utility Notice (Perm)