0308-093 (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 04/30/2(
Date /6 Signature of Contractor*�� l
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).
( ) 1, 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.
( ) 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 L 9ERT Y MUTUA1,1z Policy No. BI AH21), 004723012TI
(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 sh7 71 forthwith comply with those r�ov,Isi,s
,oL?.
Date: tidApplicant ,do.
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 made & each person at
whose request and for whose benefit work is performed under or pursuant t O
any permit issued as a result of this applicaton agrees to, & shall, indemni
& 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)
I
BUILDING PERMIT PERMI0
- 093
DATE VALUATION LOT TRACT
(.. -3 ?.3`'1'`i�c3. .85 3A35 r
JOB SITE
ADDRESS -!575 VIA -,J1. �CZffA
APN
772-250-011,
OWNER
CONTRACTOR/DESIGNER/EN (NEER
TOLL Mori i:I INC
Toll, M013 AM11 Wc.
73-121"ED WARING6}00
73.1211' IM WA ING4100
PALM DRIU2.2T CA 92260
PALM DESS T CA 92260
0660X74-%99 CPAA 3832
USE OF PERMIT
812 0LE FAMILY MMLU�1t3
SFU - LADT 8S, SEDOWAw/t, PERMIT D0E,5 NOT INCLUDE BLOCK
WAUA. POOL, SNA Oh L9KIVErWAY APPROACH. 7S%!tt?:UU 19�O�pNTO 13LAN
CHECK PEE DUE TO Ia ULTIPLE ISSUANCE OF SAME PIAN T ♦ Z PE
CUSTOM CONSTRUCTION 2,900.00 SF
PORCHIPATIO 7'79.00 SFr
GARA0111CA'i PORT 614.00 8F
ES7WATFED COST OF CONSMUC".3CJIOIf
233.733,150
Ti R'& l,' FM5 h"13 AL81Y
CONSTRUCTION FEY, 101.000-418.000 $1,100.50
PLAN CHECK PEE 101-000-439-318 �72%Si0
MECHANICAL FEE 101.000.421.000 5111.�f1
ELEC CRICAL i+ZE 101-000-420-0,00 $166.20
PLU1:3IM40 FEE 1 O1.000.419-UOO $184.00
STRONG MOTION E'- REBID 101-000-2,41-000 $23.87
GRAl)WO FEF 101-000-423-000 S0.00
]DEV LDPER IMPACT Flap $?,405.00
ART R4 PUBLIC PLACED - R.ESIE 270 -OW -445 -WO 584.33
COk1N1�13'C",71014 AND PLM C:`�1ECK
$4,32W90
LESU PRE -:SAD FM
$0,070
S71DTAr.4��,�FANDUN0W
go
$4,32490CI
RECEIPT
DATE
BY �� /
D&X FIN IN EC OR
0 14111-:K61. R
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs ---Underground
Ducts
Forms & Footings
Slab Grade
Ducts
Return Air
Steel
Combustion Air
Roof Deck Q
Exhaust Fans
O.K to Wrap
Framing
F.A.U.
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
t
Ffinal
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING P ROVAL
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out W VEquipment
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 APPROVALS
Temp. Power Pole
Underground Conduit
on
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. el
Smoke Detectors
Temp. Use of Power
Final
Utllity Notice (Perm) s-