9911-0014 (PLBG)54550 Avenida Alvarado
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 am licensed under provisions of
l-iapter 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 E . Date
-537333 Iti. B 08/31/20e
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Signature of Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, 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 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.
STATE 1 UNL) 13R;ii'31.-'4:
(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,
1 shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree hat if I should become
subject to the workers' compens.3tion-prgyisions of S ction 3700 of the Labor
Cidde, I s 411 fa ith comply wi{h lode provisions
ate: 1 i l`'1( Applicant /
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
& 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 1 have read this application and state that the above information is
correct. 1 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 propecty:for inspectio purposes.
31
Signature (Owner/Agent) Date f T
BUILDING PERMIT PERMIT#991 01
DATE t1/03/494VALUATION S1,5U L00 LOT TRACT
JOB SITE
ADDRESS 54-550 AVENIDA ALVAR DO
APN 774-27.3.003
OWNER
HERBERT 11 MOSS
10925 N BLANEY AVE
CUI'ERTINO CA 9501,1
CONTRACTOR / DESIGNER / ENGINEER
MUMI3IL, INC.
P.O. 13{)X.10758
PALM DESERT
(7r.,0):1#0--2726
CA 92255-07'
C13I..# 7526
11111111IIIII011110IIII 02
IE
USE OF PERMIT
PLvM133144-,
SEPTIC ABANDON SEWER CONNECT
VA1,Ui T TON 1.500.00 1..3
ES'1-9MATE D COST Or CONSTRUC'T'ION
PERMIT FEE SUMMARY
I UJMfi{NO 1'EE -- 8EWiiR 10i-100-419-(tO0 3:14. ou
S11 ,-1Y)1'AI. f't-'iN 1U TCTioN ANC) Pf _AN Ci. iI CR'
LES+". PRE -PAID FEES
TOTAL PERMff' VEVA 011E NOW
1Y50.1X)
.
r-
•, 7 `'
• i
L +
$30 of)
!POO
S.$0,,lXt
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
d 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 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
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
6—/ •67
S7
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)
•
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL 75849
,lIr
Received From
Date. j /3/(r.,f
Address• (� ,,)YkO <Y\ i%'x % . ��,<_ V-A"
Account No. 470 6) -= yrs �' (J - `; Lots) 2--� ••i - Tract 5 C_.
Service Address S t- - ' �- ( :ti - G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ 'Meter Surcharge
Sanitation Capacity Charge C
•
❑ WSBFC
❑ Temporary Construction Meter
❑ Turn on Charge •
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
CI Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A D - Bond
Assmt
❑ Customer Deposit
❑ Other
Remarks: Tr/ .
❑Copy to:
TOTAL $ 1 ' e)
Cash .
Check
Money
Order
C(.0
v.
Water Service
Cashier
CVWD-438 (11189)