0308-095 (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 d'� Signature of Contractor/w /&�
iJ
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 ownef 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:
Carver 1ASEI2'i Y MI)TUAL F: Policy No. WA:262DD04713012TF;
(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 s all forthwith comply with thos pr vSions.
,Da e: p-� Applicant 1A,r �= "'•� '""
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 to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
U & 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 p
BUILDING PERMIT PERMI0
^M
DATE VALUATION �. �y �y ��R LOT TRACT Ow
f �! ( . f 6�?r� e
Hv.W Y 7J.�..�41 8 � �Vw5%
JOB SITE
ADDRESS W^ 5" 'IAS I.�C.i�.�''�
APN y fA
OWNER
CONTRACTOR/DESIGNER/ENGINEER
TOLL HRO71MO INC
T01.L `DRCM RJR 114C
73 -121 FSS WAFtING;9100
73.121 F(M WARMICT4100
'PADA DESERT CIA 92260
PALM DESFAT CA 92260
(60)674-9699 C13L9 3832
USE OF PERMIT
SR401 V; FAMMY DWI 3 • ANG
SPF? - LOT 97, SWONA-f . FRF M1 IT DOES NOT TNC9.UDE BLOCK
WALLS N001., SPA OR DRIVEWAY APPROACH, 73% REDUCTION TO PLAN
CHZCK F ZE DUE TO FuFtiC.'TIP1:E ISSUANCE OF&AMIZ PLAN TYKE
CUSTOM CONSTRUCTION 2,,800.00 ;1p
PORCH PATIO ' V3.00 SF
CFARA0PJCA1rV0RT 610.00 03
COWW OF CONM. UCT9[ON
23.4,733.50
PE1;M+xT FrE ISIUMN"y
CON'STRUC-71014 FER 101.000.418-000 3I,108m
PLA14 {:HECK FZE 101-000-439-318 V".98
MECHANICAL FU 101-000-4,21-000 $111.50
EI..I&PUCALFEZ .101-000-420-000 $166.20
PLUMBING FRE 101.000-419.000 $124.00
ST'RCYN 3 MOTION F - RESITD . 101,-000,241-000 $33.37
ORAi1INO CRE 101.000-423.000 $15,00
FDFIVEL.OF'ER;MPACT ffE. $4405,r -o
ARS D! PUBLIC PI ACES - R&SIL' 2707-000.445.000 S94 #3
.3IJB-TOTA1, CONS'fii2.UCTION AND�FC 4�H�L"k
$4,374.90
PRE -FAM.
'
8
-M Fn$ DW Now
$4,324,90
SEP 2 6 2003.
CITY OF L.A QUINT, /
FINANCE DEPT, I/
RECEIPT DATE , BY DATE AL LMS1rCT0
INSPECTION RECORD
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
Exhaust Fans
O.K. to WrapF.A.U.
3,Compressor
_
Framing
_
Insulation
!
VentsON
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath ./
Drywall - Int. Lath
Final
Final
BLOCKWALL APPR VALS
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 A P V $
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping i
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer _Connection
Encapsulation
Gas Piping
Gas Test
Appliances
-
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service o.
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: