0105-314 (PLBG)LICENSED CONTRACTOR DECLARATION
v' 1 hei jy 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 # TM Lic. Class,!"' Exp. Date
1055�?s B C*
t�.
a2C
" f Signature of CDto ontractor2,�4'
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.
E r MP7
(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 p ovisions of Section`3700 of the Labor
Code, 1 shall f rthwith comply WA thos�pfovlsions.
Dgte: a f'<' Applicant' _ r � i� � t .4
Warnl g allure to secure W rkers' Com pensation'toverage 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 Q'6sentatives'bf this City to enter upon
the above-mentioned property for insA�c�6n purpos.r� ,
Si nature (Owner/Agent) �r��%'N Date J�•F•%
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01.015-314 TRACT
$.00
JOB SITE V
ADDRESS APN
-1 0 XV RNMA MO3 1,�".�l i`t£ A M
OWNER CONTRACTOR / DESIGNER / EN &NEER
82154 'fiAklQ7. rfZ; AVE,
(760)242.9175 (MIX 5839
USE OF PERMIT
k:fj10:3C TAWK #lS.e bIDC17,4MXNT - NZW)rla .f' 00KOUP
PIMINID1f+ O F 09WRR. 101 -000 -419 -OW $30,00 r;
brds $0.00
qod
9 20
RECEIPT 1 - ---.DAT.E_.. E. BY DATE FINALED INSPECTOR
90 'F EA:
FINANCE OE PT ' 1
J �i
INSPECTION RECORD r
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
• Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap.
F.A.U.
Framing
Compressor
Insulation
Vents
-Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
BLOCKWALL APPROVALS
Set Backs
Footings
Bond Beam
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection .
Gas Piping
Gas Test
Notice (Gas)
ELECTRICAL APPROVALS
Power Poli
around Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Final
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Final
COMMENTS:
CL
POOLS- SPAS
z
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
0844.$.Oc
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Received From:
Date:
Address: —-^ �
%
Account No.
Lot(s)
Tract
Service Address I /�" / ��
�% ii? Z��[ -f 1. tr1 i < G'Y:� t`'�. %./.'�
f (� G.A. Code
❑ Meter(s)
$
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
1�8 natation Capacity Charge
r.1 .'�1 0(
❑ W.S. B. F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑' Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water'/ Sewer
-
Tract -
❑ Bond Payment - A.D. -
Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL $
Remarks:
❑.Q" py to: C..�
1" C
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%Cash
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Water Service
Cash
Check
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•..�
Money
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