0103-193 (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. Dated.
044CM
Date Signature of Contractor
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 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 Policy No.
(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
Warning: Failure to secure Workers' Compensation coverage is uniawfui 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. r; y
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
& 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 -4-
Xe
BUILDING PERMIT PERMIT#
DATE jr J VALUATION LOT TRACT
�"v "lA310.1550.70 10 29349-1
JOB SITE APN
ADDRESS
— A—MGS i ON D- RAXH 1 767-490-010
OWNER - CONTRACTOR/DESIGNER/EN INEER
TOLL MfJ`1:� M134 WC 11`C)LL, 'sRelli M91:4.91A=rC
E4w923.>:r:EOWLSC'.LAMEms1,00TA12.220 '74.923110VELY1,&NF r `TE'a1''i'u-no
PALM DR&".DIRT C A. 92260 PALM 79EaM CA 92260
�,760)V, 4<9699 ORIA 3832
USE OF PERMIT
C#1nar.Akd1L'Y, F3°� AiV
I31?1.�<I?I<,< N Td:t A ROSA LOT 10 - k�U.MX Y 00-0 NOT I CLU
WPr.lra&x'��✓GJ1sfw"IPA A DUV KWAY AP'P1'✓.O.i Qf 1,
CUSTOM CONSTRUCTION M.00 V
PORCH/pA11110 334.00 31`
(MritRt,})F/C.AkiPM (SY) 14,%16.60
'.t`,1].0'WF`ED falls' ov CON 'MUC1:I01,4. 310,550.70
d;OM'1RUCTION 1'78.
)O1 -M-418.000
MR
282001
101-000-4,39,318
$1,094.70
ITY OF LA OUINTA
101-000421-000
$96:5.4
FINANCE DEPT
101,000.420-000
'.t`,1].0'WF`ED falls' ov CON 'MUC1:I01,4. 310,550.70
d;OM'1RUCTION 1'78.
)O1 -M-418.000
$1,:M0It
PLAN CHWK PPL"
101-000-4,39,318
$1,094.70
MWHIAMtCAL FU
101-000421-000
$96:5.4
EEuN'.t;:'1 TICAL ME
101,000.420-000
$1179.56
PLU1taJ0:THOVER,
101.000-419.000
$160.00
FR - I?X310
101-00p0w-241j-000
$31.06
�3gTR/�M11y0
pl�t�p�7s�Tp103
47�.f'��d�d T� \i I' L' •�y
.i !7I ^�SiV �N�a� ��� V'
,P 6 V' -i V N
O1^'VElrOP MPACT r1,?
$1,907.00
X&RT rN PUBLIC K.&C1.3 - RE11p1: 741 *000-255.300
$2116.36
IMS PRE -PATO M-101
TOTAL rMMYV PEES D UE NOW
RECEIPT DATE BY I DgTFI)
&f/O / I INSPECTOR
e
$5,145.29
$0,00
"114529
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings / / / _ _ Ducts
Slab Grade Return Air
Steel _ _ Combustion Air -
Roof DeckSl �p Exhaust Fans
O.K. to Wrap / F.A.U.. .
Framing ' _ _ Compressor
L P
Insulation �.� /p JAZ _ Vents
Fireplace P.L..U.t7 Grills
Fireplace T.O. Fans & Controls
Party Wali Insulation Condensate Lines
Party Wall Firewall `
Exterior Lath
Drywall - Int. Lath
ZRA" i _
Final
Final � �Z/��/
POOLS -SPAS
BLOCKWALL APPROVALS Steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final Gas Piping
PLUMBING APPROVALS Gas Test
_ Electric Final
Waste Lines D/Q� (/r Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans O.K .for Finish Plaster
Sewer Lateral _ Pool Cover
Sewer Connection �'�s/j,Y 6/V Encapsulation
Gas p
FG77--as Test
Applia
Final
COMMENTS: .,
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS ,
Temp. Power Pole
Underground Conduit
Rough Wiring
Lav Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final,
Utility Notice (Perm)
J
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS: 81-245 KINGSTON HEATH
s
Use Classification: SINGLE FAMILY DWELLING Bldg. Permit No.: 0103-193
r Occupancy Group: R-3 Type of Construction: VN Land Use Zone:' RL
Owner of Building: TOLL BROTHERS INC.
Building Official
Address: 74-923 HOVELY LANE EAST STE 2-220
City: PALM DESERT, CA., 92260
By: GARY HARTMAN
Date: 12/21/01
POST IN A CONSPICUOUS PLACE
Al Miller a sons
Al Miller & Sous Its otilig
Roonng
inc, � Gu -iso Sununit Ur. 1'horie: 7F0/3�]6-1.21.4
Ca' die dral Giiy. Ga 92L31 �''iix: 766/311-7097
YrN Cirilry / AWy
Via.: 7771.5,96
F"orn: Russ Mil er
Gate: ' I.
Re: !Inspects n
Pages: 1.
Gary / Andy,
We have inspected alll
Reserve), All vents I
specificatio' ns and per
Thank you,
Russ (Miller
Brothm,,sPCTAWest
T
I
the Roofs at PCA West"and
are installed per the Q' 'gin
your plans