PLBG (9708-095)54280 Avenida Madero
9708-095
LICENSED CONTRACTOR DECLARATION
I here Fv affirm under penalty of perjury that I am licensed under provisions of
L hapt 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 r Exp. Date
Jw
C-42 1 Ur3119 y
Date Signature of Contractor
OWNER -BUILDER DECLArTION
r
I hereby affirm under penalty of perjury that I am xempt from the Co; ractor'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.
.;T'.17I4 t :1— t::^t;tt: 1'tf
(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 d. s all f rthwith comply wit 'se,prr,visioris.
Date: r Applicant'
War, g: ailure to secure Workers' mpensation 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.
PERMIT# CONTROL#
BUILDING PERMIT
9708.095 5764
DATE VALUATION '011.400.00 LOT TRACT
JOB SITE ADDRESS `4-280 AVENMA Ii9fclDERO IAPN
1.-Y ...
OWNER I CONTRACTOR / DESIGNER / ENGINEER
!,A QU,1*. IVA U:EDE': Acr:111!(7 V 17cf)r :, CIEVIEP, SMVICE
78-4951 Ai.t, 's'tAMPICO P.G. BOX 1421
LA QI-1191-A CA 1 21S3 PAIM T`)TsSFR T' i:!•l011
Tj.7R t .9.12
1,76( ,) s61-2i93 \ 1)t,4
USE OF PERMIT
T•Li_t 113
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►'i.l, UwlTS1 tJ;) T -'U 1i -- ; tJrW►l: 1411 Aft -410-4)(9)
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 ;Z;
' the above-mentioned property for inspeection purposes. RECEIPT
Signature (Owner/Agent)/w+7 " 7 Date
i
4ftT:-1i:l`VA1,C 1NIN'"}tIXTICWA1`4117)llf.AN01FCK
LEETS 11R.&N-MO FFIES
Kfil'Ai, PERMIT FFI;;' ► nils'. hi<i V
DATE I BY I DATE FINALED I INSPECTOR
"11.01)
C
INSPECTION RECORD
t
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
BLOCKWALL APPROVALS
POOLS - SPAS
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
final
Utility No ' s
ELECTRICAL APPROV S
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)
COMMENTS:
ECONO SEWER SERVICES
Q P.O. Box 192
PALM DESERT, CA 92261
Phone 328-7760 346-2793
Am oaaawL .
N2 8026~..
jDATE OF ORDER
CUSTOMER'S ORDER NO.
PHONE
M HANK H ER
START NG D TE
TOTAL LABOR
NO STATEMENT WILL BE MAILED
TAX
BIL
DATE COMPLETED
ORDER TAKEN By
J
XUDRE
_
DAY WORK
CONTRACT
EXTRA
JOB NAME AND L A N
-
JOB PHONE
PLEASE PAY FROM THIS INVOICE
Signature
s
No one home - Total amount due 0' Total billing to
-for above work or be mailed after
completion
I hereby acknowledge the satisfactory completion of Work
of the above described work
TOTAL MATERIALS
TOTAL LABOR
NO STATEMENT WILL BE MAILED
TAX
DATE COMPLETED
WORK ORDERED BY
TOTAL AMOUNT
Signature
s
No one home - Total amount due 0' Total billing to
-for above work or be mailed after
completion
I hereby acknowledge the satisfactory completion of Work
of the above described work