PLBG (9610-080)52430 Avenida Martinez
9610-080
LICENSED CONTRACTOR DECLARATION
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Cthapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License•is arfull force and effect.
O Z) M License # Lic. Class Exp. Date
ww 31 a A 1013I197
ZO r Zat - "Signature of Contrac or
CD ~M OWNER -BUILDER DECLARATIONI hereby affirm under penalty of perjury that"yI 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).
( ) 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
N Date Signature of Owner
ON
rn
Q WORKER'S COMPENSATION DECLARATION
CL
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
F- O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w Y= compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
M Q C) I have and will maintain workers' compensation insurance, as required by
O UQ Section 3700 of the Labor Code, for the performance of the work for which this
d U-) f— permit is!issue"d'I, Wi\Wo5rkers' compensation insurance car'rierli&:policy no. are:
,It Z Carrier Policy No.
Cb =)
r` a
Q (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
3 subject to the wqrkers' compensation provisions of Section 3700 of the Labor
Coded sl7a tifo fi comply withse provisions.
,Date: //'7 Applicant
Warning: Failure to secure Wor 7s' 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
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 upo
the above-mentioned psope`rty for inspection spection purposes.
VSignature (Owner/Agent)•.'' Date/ A Z
PERMIT # CONTROL #
BUILDING PERMIT
4255
DATE 10/23/X6 VALUATION 1I,Z(M" LOT TRACT
ADDRESS S7.-430 A ri . NIDA t il.`iil liNEZ JOB SITE
APN 77.3^277.-069
OWNER
CONTRACTOR / DESIGNER / ENGINEER
]CIEUR A MARS1 AL1,
:.1.MES R.. itjAS(JIN
52430 AVENIDA t IAM'INFZ
787,15 VIA ME .1,01)[A
LA tiyUIKI'A C'A Q2253
PAIAI DESPIRT CA 92260
tt;19YVA-48s4
ft;l >1S(,:!-2d 10 01.11.# 1 IiiS
USE OF PERMIT
SLIKFIC: A.BANTA-K SRWHR IK40K-IIt'
1Trlt.iJtt1't(dN t,;7SJit.Ut! l,S
L7
US1,11MATED C0,3 [' OF C ONS I s\7111a.f IGIN
3r21 i►P.1
t' .l<M 4'1' +'h; F; tid I M tt'lAii'►'
(JI,UNM(N0 FEE _. SR-m"R lot -W0419 -M) 130Y)
SU13-TOTAI, CONSMUC'!'ION AND MAN 011134 K
$30,00
LESS PRE -FAIR I EEr s
Y,Ii.Ut)
1'01'AL PERMIT h EEE l)VE rYCAV
O
ID
OCT 2 3 1996
F ECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE"
I 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
Fir lace T.O.
Fans & Controls
Parry Wail 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 Pibg. 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 X
O.K. for Finish Plaster
Sewer Lateral 44
Pool Cover
Sewer ConnectionEncapsulation
Gas Piping
Gas Test
App"races
Final
Jr
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)
COMMENTS:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL / / 15-94 r
Received From: Y `Z A ,'S P6 L L o P L L5- i- A /k iM "t`. 1-{ j, cJ ""t —Data: 1-0- ! 5 94
Address: 552 - !Q 30 AV F.. , M AP'17! A,1 2, I—A 6 CI 1 AT -A CIA • / Z i
Account No. ,e _x _ig C1, 6 ep Lot(s) 14 B tk, M70 Tract SC, l
Service Address fi Q VE /41,6 VMAJ r Z_ G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge ^)
anitation Capacity Charge _Ss •- l f-. 00_
❑ W.S.B.F.C.' Y
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract - .
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt. P
c.,
❑ Customer Deposit s, +
❑ Other
TOTAL $
Remarks: k
k:
vj;6 to: .5 7z2 cec
CashWater Service
,, A
Check $' '
Money Cashier -
OrderVWD-438 (11/89)
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SANC
PUMPING SE2VICE.-( L
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1
2502 Morongo Trail
Palm Springs, CA 92264
(619) 327-8859'
N2 10327
SOLD TO
SHIPPED TO
fS*REET NO. STATE
STREET NO.
A
CITY .STATE ZIP
CITY STATE IP
0
CUSTOMER ORDER
SALESMAN
TERMS
A
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AYM-E-NT•,DUE UPON RECEIP