PLBG (9903-188)54100 Avenida Madero
9903-188
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
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Z.
O Date Signature of Contractor, ' •« >
-
J V C) OWNER -BUILDER DECL RATION
HaLU r- 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
M ()
u7 I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
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FL Z WORKER'S COMPENSATION DECLARATION
C cc I hereby affirm under penalty of perjury one of the following declarations:
U') O ( ) I 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
O Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Section 3700 of the Labor Code, for the performance of the work for which this
IlLOH permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier Policy No. r y(
t :i1.!)1s d 4:11 41'. INii. 'r. C It, J 111•Q(;
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(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 Section 3700 of the Labor
Code, I soh II forthwith comply with those-provisibns.
Date: Applicant - -
4-11
I v
Warning: Failure to secure Workers' ompensation co erage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation,lydamages 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 propA ®rinspection, purposes. j✓
Signature (Owner/Agent) Date fl
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 99I0J_JXi TRACT
3118M S 1,400 -Ilii
JOB SITE APN
ADDRESS 100AV1id` IDA. MAI)ERO -
OWNER CONTRACTOR/DESIGNER/ENGINEER
17184" 1 ANIERICANI 'i'fiIX. CO ECIONO sl"sW!• R SERVICE
,15.200 CLUB DRIVE 84035 CAU2ON RD. [ND1O, CA 92201
1NMAN WELLS CA VA1,M DES EkT CA 92.241
(,7ti1)13A< -^ 79Z CBI.ft :kit
USE OF PERMIT
4 Lu 1•a1N ;
SUM, ABANDON SEWER ili%x:wKUP
VALUATION
11,400.D) LS
s j j( yy. (j {1j ,j jp' { i'\' 'TP r '!`: L"f. 'T OF("CZ: '-tti.1crION I,-ffs!13. M
fT
} VJM1411 C; FLE -- :3}3b4s 101AW-41 0)0 S -U).
00
SI jii'lY7iAl, {'r Nti i FIt ft."T ftfl+fNfl 1+I,. ivr i'1Ff"K S i(i (rn
LESS PR1:TA10 FEE'S 50.00
't'OTAI.1'Fitf!UT FYVAS DUiH;NOW 1 5311.22111,
RECEIPT `` DAT t ( BY DATE FINALED INSPECTOR
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
0.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 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 LIE
Encapsulation
Gas Piping
Gas Test
Appliances
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)
72361
Date: 3 % 7" r/ i/
%.3
Water Service
Cashier `
CVWD-438 (11/89)
;I
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:
Address:
r_1 14 In
•, ::;, i
/t l
Account No. Lgi069L1 2 r fCC l
2,
Lot(s) Tract_
Service Address
G.A. Code
❑ Meter(s)
" - •'i"
❑ Service(s)
t
❑ Backflow(s)
❑ HouseLateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
" {
QXanitation Capacity Charge
" i
❑ W.S.B.F.C.
❑ Temporary Construction Meter
7
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
7{
❑ Plan Check Fees Water / Sewer -
Tract -
j
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
' {
❑ Other
1
TOTAL
Remarks:
/rl
{
dopy to:
Cash L/
i
Check
Money
Order
72361
Date: 3 % 7" r/ i/
%.3
Water Service
Cashier `
CVWD-438 (11/89)