PLBG (9904-056)51920 Avenida Martinez
9904-056
I
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
-;,haptbr 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.
O ch License # Lic. Class Exp. Date
O tl 1. A 10131/99
Z r- D to /ignature of Contractor
Zoog li
U OWNER -BUILDER DECLARATION
UJ H LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason:
Z_ ( ) 1, 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 LO t under Section , B&P.C. for this reason
t
N Date f d ,/ Signature of Owner
o rr
d Q ' WORKER'S COMPENSATION ECLARATION
p zCc I hereby affirm under penalty of perjury one of the following declarations:
Lo O . () 1 have and will maintain a certificate of consent to self -insure for workers'
X W u- compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q per( mance of the work for which this permit is issued.
C0 Q U (/Q1 have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
CL:
0 Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
C) STATE YUND 6 12 --lit
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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 he orkers' compensation provisions of Section 3700 of the Labor
Co I;S 7b,
hwith comply with t s provisions.
gate: t' Applicant
Warning: Failure to secure Worke Compensation coverage is unlawful and
shall subject an employer to crimi al 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 up n
the above-mentioned property for. inspection purposes. % j
Signature (Owner/Agent) Datef
i
BUILDING PERMIT PERMIT#
VALUATION IISltf .00 LOT TRACT
DATE 417/"
JOB SITE
ADDRESS 51-920 Ati'I! N1DA Rirllit FINEZ
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
JOE[, CRAIG BOECKNIAN NI
1AIMES 1t. N. IASC)NI
51920 AVEiNIDA MARTINEZ
787,15 VIA MELODIA
LA QUINTA CA 92253
PALM DEiSI?RT CA 912W
(70).1 SNE -24th c'I3I.# I ltig
USE OF PERMIT
SEWER COW" T, SEPTIC ABAN0ON1i 3 iNT
VALUATION 1,.5(1[1.311 LS
i;C '[i)R
2 „5;;:t.Ait
PI MUT FCTI, SUMMARY
PMANIMiNGf-174 — SEWER 1014)00-419-000
80R-•rt'1'1'Al, (T)Nrw rRC,.tf r10N AND II1.AN Ciff-CK
LESS I .tli-P111I?t L:fiS
$00:1
'FOIAL PKI01111r#;WS DUE, NOW
S3413")
RECEIPT// ele
DATE
BY
DATE FINALED
INSPECTOR
- -
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zr -4111 1
M
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
OPERATION
DATE 7
INSPECTOR
Y 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 fol' Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection - —
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final y
Utility Notice (Gas) ,
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
,
iELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Remarks:
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Trac t_J
G.A. Code
TOTAL
• 72765
i2 Fv
WaterService
Cashier
CVWD-438(11/89)
Received From:
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Address:
Account No. d
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' 7Lot(s)
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Service Address 2
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❑ Meter(s)
❑ Service(s)
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❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check(s)
❑ Meter Surcharge
• ,f
anitation Capacity ChargeO
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❑ W.S.B.F.C.
❑ Temporary Construction Meter
' !
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee-
ee-
0
❑ Plan Check Fees Water / Sewer -
+
Tract -
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❑ Bond Payment - A.D. -Bond--.
Assmt.
❑ Customer Deposit
{
❑ Other
Remarks:
• .. ':_. . /cam , .. _
Trac t_J
G.A. Code
TOTAL
• 72765
i2 Fv
WaterService
Cashier
CVWD-438(11/89)
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2502 Morongo Trail
Palm Springs, CA 92264
(760) 327-8859
S O UDA_gTO
SHIPPED TO
SVREET % %L jN6. STATE
/
V15-
STREET NO.
CITY //^ STATE ZIP
CITY STATE IP
CUSTOMER ORDER
I 1VALESMAN
TERMS
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PAYMENT DUE UPON RECEIPT