PLBG (9906-043)52480 Avenida Madero
9906-043
',LICENSED CONTRACTOR DECLARATION
Ujr V eby affirm,under penalty of perjury.,thatd'am licensed under provisions of
.. - _
rChapter 9 (cdmmencing•,with Section 70Q0) of Division 3 of., -the Business and
&Fcu:`w" Professionals Code;_ and my License Is rn full force and effect.
,'O. rrhj ' License # ' t LIc .Class Exp Date
CY LO
4-92 16
' , 'T' '.ti„"• '. r. r 9 ' 'fi 1 S 1..e h.,'-,t
Z V Date's•Si nature of ContractorX - t ` ti ; d' ^
H o t, _ OWNER -BUILDER DECLARATfON .
WW I hereby affirm under penalty of perjury that I am exempt from thle Contractors ,
License Law.for the following reason.
Z . (:) 1, as owner of the property, or my employees with Wages as' t herrjsole
=) compensation, will do the work,,and tl e'struciure isnot intended or"'offered for
sale (Sec. 7044, Business & Professionals Code)., S r'Tw'
(') I,;as••owner of the property, ith am exclusively contracting wlicensed
contractors .to construct the project (Sec. 7044, Business & PUofessionals
Code).
O I am exempt -under Section B&P.C. for this reason •14. s
' N' ` Date • Signatdre of Owner
'0
U Q • WORKER'S COMPENSATION DECLARATION
z
t o'er I: hereby affirm 'under penalty,of perjury one of the following declarations:
0` O l have *and will maintain a certificate of consent to self=insure.for workers' ,
X: W LL compensation, as provided for by Section 37b0 of the Labor Code, for the
0 rJ Q performance of the work for which1his permit is issued.
Q O ) I have and will maintain workers' compensation insurance asrequiredby
O' Sed
on
ed
on 3700 of .the Labor Code, for the performance of the work for which this
d'jLO = permit•is issued. Mei workers' compensation insurance carrier &.policy. no. are:
?. z Carrier Policy No.
Q (This section need not be completed if the permit valuation is for $100.00 or less).
= O 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
Y + pode, Lshall forthwith comply wlth•t6o a provisions./,
s ' Date: / a , ! /.`•r,Y 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
` foi 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
r & 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 properly for inspection purpos/es{/. /!1
,
Si nature (Owner/A ent) "' "" ' "` '* ''`""•Date t%
BUILDING PERMIT - PERMITS
DATE 06107119!).VALUATION $1,050.00 LOT
1
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JOB SITE y, !, •,. };,
ADDRESS 52- 0 AVE-11t :1 ,1.. dl.F lD .+ iO..
APN + ,% •t
OWNERC ' • , = .' -
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ONTRACTOR / R / ENGIN -
DESIGNER ENGINEER
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38-703 VVfgrA DRIVF, Ij t
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(7600324,1911' . criU 7619
USE"6FlPER('MIIT
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V f tY 7C ABAN aNK31,Ff AND WT-11JOMT. 404
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PLUMBING FJ' E - SEWER n30.00
S0:F321"L TA_1, CO S'1'RUCi'1ON AND P:Ief1N CN.ECK
MOM
LESS PRI: -ROM FEE'S
$0.00
' iff3' °tit..' flii" ::'.E; 'i)uri.NOW'
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RECEIPTDATE
BY
DA &FI A D
INSPECTOR
A
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w ; c r•.
INSPECTION RECORD
OPERATION
i
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts T
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 Plbg. 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
Appliances
Final
COMMENTS:
Final sy
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
1
CASH RECEIPT DETAIL
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Received From: t , )Ajl ' —1-114,k)
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Date:L7
1 . wY /Ij
Address: %ii7 11
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_
`7 3
Account No. (•- S- )%t
.l).7. Lot(s) (_
!( / Tract
Service Address
G.A. Code
W J'
❑ Meter(s)
$
❑ Service(s)
` ❑ Backflow(s)
❑ House Lateral(s)
❑ Detectorcheck(s)
❑ Meter Surcharge
0 Sanitation Capacity Charge
'
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract '
i
Fee -
❑ Plan Check Fees Water I Sewer -
i
Tract -
l
❑ Bond Payment - A.D. - Bond
.
Assmt.
❑ Customer Deposit
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❑ Other
1
TOTAL
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Remarks: / ''l ; TI :fl C
!i- . i i r`(i/
iq'Copy to:
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CashWater
Service
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Check
Money
'
r
Cashier
Order
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CVWD-438 (11189)
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