9609-121 (PLBG)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
480961 C,-42 r 1613 1/9 7
Date�j
Signature of Contractor
F L1
OWNER -BUILDER DEC
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).
() 1 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 oftheLabor Code, for the performance of theworkfor which this
permit is 1Wh;=d`.�fv1lly' "o�kers' compensation insurance ca4rie� &� 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 pfovisions.
at
e:: Applicant's^?:�!/k�^�-�--
Jw .- �.
Warning: Failure to secure Workek' Compensation coverage is unlawful and
Shall subject an employer to criminal penalties and civil fines up to $100,000, in
Addition to the cost of compensation, damages as provided for in Section 3706
if the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director.of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to; & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees:
2. Any permit'issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all_City, and State laws, relating to the building
construction, and hereby '5 thorize'representatives of this City to enter upon
the above-mentioned property'fo inspection purposes.
r"
Signature (Owner/AgeDate �/= ✓fie
PERMIT # CONTROL #
BUILDING PERMIT 9"9.121 . 4094
DATE 9116/46' VALUATION SI,Q4?4l,40 LOT TRACT
JOB SITE
00 AiiENUM�3.Id5'Yi1:C:ON'
APN 773-2515_006
ADDRESS .i2,-
OWNER
CONTRACTOR/DESIGNER/ENGINEER
V.O.N, F'MC
1Jr01140 SEWER SERIVIC E
191.5 MORENA BLVD
84035 CARAWN RD.
SAN 1.)1E:C:0 CA 92110
PA•l,M OF—SFWr CJS 9226.1
f'27f*it.�i27-1
(E19,13�db2i9= Clil.# 342
USE OF PERMIT
Pt.<11iVit'i1N01
SEWEIR("ONN13CI7SEP<1'1C A13ANENDN
Ma s MUTED CWT 01." :`OldlYfiz' IC,"1'@ON
1, i6:84r,
P RRII'1' VEiEt`, Si1:U AMARN"
PLUM61,1NO FPF!-- SEWER 101.000 -419 -OW :$VX*
SL1h-1 Y'I7AL ('0N91'RUC'TI0N AN PLAN C.T•ti3CK
$30,WJ
1XISS PRL-VAID F Xi'S
$0<00
n
n I I )'$'flB., 4'Bf;I�tNE!"E 1+':t l;+.a 139.t1F -NOW
- -
Ll
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SEP 16 1996
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
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 Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali 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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater 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
Ap li
Final
COMMENTS:
Final
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)
ICU
, Z
ECONO SEWER SERVICES
P.O.'Box 192
�PALMy DESERT, CALIFORNIA 92261
AMMOM 00 E
-47620
PHONE 328-7760 346-2793'
A
CUSTOMER'S ORDER NO.
PHONE
M HA(N%K,�/
H PER
ISTIARTING DA
BILL TO
ORDER TAKEN BY
ADD SS
/
^"•
❑ DAY WORK' .,
ICI
E) CONTRACT,
Y
EXTRA
JOB PHONE
�- PAYMENT TERMS NET fn DAYS FROM ATE OF SERVICE ' "P
3;rh% PER MONTH CHARGE AFTER 30 DAYS
TOTAL MATERIALS
TOTAL LABOR
a.
—PLEASE PAY FROM THIS INVOWE
NO ST MENT WILL BE MAILED TAX
FLET WORK ORDERED BY
117 TOTALAMOUN
one a *r[:T—Total amount due Total billing to
Sig t for above work: or be mailed after
completion
PRO= 2584 ds Ina I hereby acknowledge the satisfactory completion
Groton Mm 01421. • • of the above described work, of Work
;yp