0209-103 (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
�atlC1 T
Date e �! �" Signature of Contractor,d'�%�""�
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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.
I have and will maintai6,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 PACIFIC XM1'LOYEF4 Policy No. 911.,13 043084 31 8
(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 f rthwith'cdmply wit those,pr pr isio
lDate: a Applicants %. F °. ` " «- ..-� -•�••
rWarning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an:employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
Of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit" subject to the conditions and restrictions` set forth on his
application.
•7
1. Each person upon whose behalf this application -is made & each person at
Whose request and for whose benefit work is performed under or pu,r$uant•to
any permit issued as a result of .this applicaton agrees to, & shall, iridemnify
& 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 applicationand 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
thee above-mentioned property for inspection purposes.
'Signature (Owner/Agent)& Z; i + t°" ". Date`wry ® �
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3 X;f;:.70
PLIMMITJF , *7 SINWAPS
BUILDING PERMIT
PERMIT# r�Elk
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DATE .N ! ' VALUATIONLOTTRACT
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ADDRESS &D- .3 V1AT A VAR
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$199,6if1
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OWNER
CONTRACTOR/DESIGNER/EN hINEER
TOLURRO L.:1'1RR 8.r WC
TOLL
$19A,t1•0
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PAI DMSY CA 92260
faAIM' DESM
CA 92260
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(760)W4.9699S.
3832
USE OF PERMIT
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PLIMMITJF , *7 SINWAPS
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CONSTRUCTION F0,
101000-418-000
$1,4. 400
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1:777 SEP 2
E _- =V. . A 11 1 BY . DATE FINALED JINSPECTOR '
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
IMECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Oombustion Air
Roof Deck
aust Fans
O.K. to Wrap
�F!A.U.
Framing
_
Compressor
Insulation
_ _
Vents'
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING AP ROV
_ —
Waste Lines �b� S
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
/L3
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
' 1 � `r �^V/
n_
1 J & 'v, V , L,
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
-
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
3-.'Z • o S