9802-140 (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
N W Professionals Code, and my License is in full force and effect.
C; =) ch License # Lic. Class Exp. Date
r` CY V7
~ Z t— Datee., ! Signature of Contractor
o
/
r— F— C:) OWNER -BUILDER DECLARATION"
HW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
co () I am exempt under Section , B&P.C. for this reason
u
N Date Signature of Owner
ON
rn
d Q WORKER'S COMPENSATION DECLARATION
p cc I hereby affirm under penalty of perjury one of the following declarations:
Lo P O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q performance of the work for which this permit is issued.
Q V (��have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn F— permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carrier Policy No.
cb Z)
r- Cf STATE FUND i)046 -93-0(X') )9
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
subject to the workers' compensation provisions of SecticL 3700 of the Labor
3 Code, I shall forthwith comply With those provisions.,..
Date:` . J/f Applicant r . _...� 7'r;�'"..
/
Warning: Failure to secure W kers' Corhfpen ation 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 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) r —��-+� ^� Date ��7� �f
% C, 77 - _.
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT "02-140 TRACT 6598
2/26/98 $1,695.00
JOB SITE
APN
ADDRESS
53-300 AVE. MU'N'! F UMA
OWNER
CONTRACTOR/DESIGNER/ENGINEER
WILLIAM W CIBSON
ECONO SEWER SEKVICE
53300 AVENIDA N10NTI:Z.CiMA
P.O. BOX 192
LA Q111NTA CA.92353
Pcl►Ll�i DESERT CA 92261
(760)34&2793 CBL# 312
USE OF PERMIT
PI et Iki 3
SEPI IC ABANDON. SEWE'R CONWX-f
c'
icon,RAi T ri1L OU`f 1,695.71) LS
L'»S•iIMATED CO,S'I' Ole Ci3N3'l'TtIXJION
1.695.00
PERMIT FIEF SUMMARY
PLf.1NWMG FEE -- 5MkT- i 141-040-4194000 S kl
CIO
Olt
cc
.�.,CIO
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SUB -TOTAL CONSTRUCTION AND PL kN CIII:CK
b30.o6z
LESS PRI: -PAID 14:ES
$0.00
TOTAL PERMIT FEES DIJE NOW
530.00
RECEIPT
DATE
13Y
DATE FINALED
INSPECTOR
wZ�wQ�
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 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 Pibg. Test
Final I I
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
App 'antes
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)
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL '
� X86812
f Received From: �) t- L I A P" G ! P S 4"O Date:
Address: 53 3eo mA�� n roeAr Zu�,A- [.
,A. (�IAJ7 r� Z
�nG) �1 Lot(s) :z- �' �,—r� J! ted) Tract
n�tTA Pig i2 wt [. r TA
Account No. ___ „rte—..T
Service Address -12 "30Q V -,,A j l Thi i✓ZOA/7•T: L G.A. Code
: E O Meter(s) $
j' O Service(s)
❑ Backflow(s)
O House Lateral(s)
t ❑ DetectorCheck(s)
❑ Meter Surcharge
:, •:;� fl talion Capacity Charge
..'.I O W.S.B.F.C.
❑ Temporary Construction Meter.
❑ Turn on Charge
::'1 ❑ Uncollected Account -Name
.', O Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
i{ O Bond Payment - A.D. - Bond
]" Asamt.
" O Customer Deposit
❑ Other
( TOTAL $ i `"� 2-7
Remarks:
7f�dpy to:
Cash j� Water Service
Check UI GD
I. Money Cashier
tt Order CVWD-43801/89)
`�' .......
ECONO SEWER SERVICES
P.O. Box 192
PALM DESERT, -CA 92261
AM �omvMEa
N2 - 8459
rnvne 02-0-1100 s40-ciVs
TOTAL MATERIALS
CUSTOMER'S ORDER NO.
PHONE
NO STAT MENT WILL BE MAILED
TAX
STARTING DATE
D CO LED&
Y
:2;�
:;;5�[:PER
$
BILL TO
ORDER TAKEN BY
ADDRESS
2 v 1
CJ
DAY WORK
CONTRACT
CIT7_
EXTRA
JOB NAME AND LOCATION
JOB PHONE
PLEASE PAY FROM THIS INVOICE
-No one one home -No one home ❑ Total amount due Total Idling to
Signature for above work. or be mailed after
I hereby acknowledge the satisfactory completion 0 completion
of the above described work Of work
TOTAL MATERIALS
TOTALLABOR
NO STAT MENT WILL BE MAILED
TAX
D CO LED&
Y
:2;�
TOTALAMOUNT
$
-No one one home -No one home ❑ Total amount due Total Idling to
Signature for above work. or be mailed after
I hereby acknowledge the satisfactory completion 0 completion
of the above described work Of work