0109-197 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F— 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
N
t W
O D r)
r-- r 475515' A B /30/2C
oZ.� I'Date Signature of Contractor r'r -'r:, t b,
N- O O (""" OWNER -BUILDER DECLARATION
JUcO s
HWW I hereby affirm under penalty of perjury that I am exempt from.the Contractor's
U) License Law for the following reason:
Z ( ) 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).
ce) () I am exempt under Section , B&P.C. for this reason
La
N Date Signature of Owner
ON
C7
d Q WORKER'S COMPENSATION DECLARATION
2 I hereby affirm under penalty of perjury one of the following declarations:
CC
I- 0 ( ) I have and will maintain a certificate of consent to self -insure for workers'
W compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
< U ( ) I have and will maintain workers' compensation insurance, as required by
0 Section 3700 of the Labor Code, for the performance of the work for which this
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
ab 5 1""� AT.i . FUND
0
J
(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
la subject to the workers' compensation provisions of Secti n 370/ of the Labor
z . Code, I shall forthwith comply with those, rovisions.
Date* Applicant
i..,."-„
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
ir 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 la relating to the building
construction, and hereby authorize representatives /of this City to enter upon
the above-mentioned property fot insp� f n rpf
poo S.
erection
Date
P.O. BOX 1504
(44-00-(10137f*
Signature_(Qwner/Agent)
BUILDING PERMIT PERMIT#
DATE VALUATION EOT • » 0109497 TRACT
09.f21 nor 22sn°
JOB SITE
APN
ADDRESS
54-ft.15 AVr 3DA A+W
- -
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CARMEN i N VALENCE
TRI STAR CONSTRUCTION'
54165 AVENIDA ALVARADO
34 730 DA71: PALM DRIVE
1 (PINTA CA 92253
%'_ IfORAL OTT ' CA 92 235
k 760)32't -0$98 Ci3I.ii 762
USE OF PERMIT
PLUMBING
:SEPTIC.AB1bNDOiNMENT; 3k MR HOOKUP .
V'.AWA,7'3011 2;250.44 L$
ESTIMATED CO 'I' OF COMrRTJMW
2,250.00
PERMIT Ft'Y SUMMARY
PLUMBING FRE -.. SEWER 1 O1.000.419-000 SAO
'
D
a n
11
SEP
21 2001
pl-j;1,1 .
CITY OF
LA QUINTA
FINANCE DEPT. ______
SUB TTTION AND PL.A,N CHECK
-TOTAL CoN C
$30.00
LESS PRE—PAID I
$0.00
TOTAL PERMIT r.b TATE X1OW
&luso
, k.
111E11111111111111111 04
IE
RECEIPT
DATE
q)/2 ! !f -i
BY
DATE FINALED
INSPECTOR
•
0
INSPECTION RECORD
OPERATION
DATE .
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum 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 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 'APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
-.kg'/W2/O/
57--
Pool Cover
Encapsulation
Sewer Connection
Gas Piping
• Gas Test
Appliances
Final
COMMENTS:
J
/wok 4/
Final
_'iizelie
Utility Notice (Gas)74074-9-2-
` 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)
oop'19.2081 15:33 7603411312
FARMERS INS
41099 p.0$3/003
cOACHELLAVALLEY *ATEftDISTRICT
1.1 1 111 CASH RECEIPT DETAIL t
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noorvi"ols)__ -- --'— — -- — -- --- --- --' —
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II
r/ w=se Lateral(s) — — — — — ------.---
O Detector c°=w"` _-_ -_' _ ---' --- --- --- --- '--. --- -- ---
U Mater ��'�` ���
Surcharge _- _;--_-
���C��m� — —���—' ._ -- _/�`�-'-
__� _-- -_' _-_ __ __ ---- __-
/� ws�m^p. _ ___ __�� ___ ___ ___
L1 Temporary Construction Meter _ ___ — —
11 0 Turn on Cnarge
U Uncollected Account - Name
n Iospecmppwo'nam'- _-- —
---
m= *-- ----- ---
O Plan Check Fees WaIer / Sewer •
Tract • -- _-- _-- -_. ---
// Bond payment A.O. - _-_ Bond _-_ --_
«ssm^__ ____ —
n Customer Deposit
__
Che4Y to:
rash I
Check
Money
Order
/.
^)r."/�(/
TOTAL
CVWD-430 vain
.