PLBG (9810-199)53275 Avenida Martinez
9810-199
LICENSED CONTRACTOR DECLARATION
U)-/V-j.hereby affirm under penalty of perjury that I am licensed under provisions of
E— 'Chapter 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 :D ch License # Lic. Class Exp. Date
► d C, 16 C 3 7131/(30
LU
oZ Date 1i)" Signature of Contractor
(DOr
J U OWNER -BUILDER DECLARATION
WLU 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C0 () I am exempt under Section , B&P.C. for this reason
Ln
N Date Signature of Owner
ON
O)
d Q WORKER'S COMPENSATION DECLARATION
p 2 Z 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 !-_ 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.
In Q U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d 0) Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
ob5 C"l.MWNl:t,:'NA110, 011 k1,11752W,
► o
J (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",
laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of,,the Labor
Code, I shall forthwith, compty`with those provisions. jf
i
ate: 1! - - `App licant ",_ e`
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
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 it
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 property for inspection purposes.,
WSignature (Owner/Agent) = '' !` t Date
BUILDING PERMIT PERMITy#8iu-11" CONTROL#
DATE 1(}/j}}/ VALUATION LOT LOT TRACT 8572_
JOB SITE
ADDRESS :?X275 AV.a:wl 1DA 1 l ..T 11NEZ
APN 774-091-0114
OWNER
CONTRACTOR/DESIGNER/ENGINEER
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l !t. ill a + ♦NY V 12Z
uurr:a;r"Rl tt t txaa pr
A I.l. i..l Ts i.. lI /sV1ll 7 '1
53-275 AVENIDA MARTINEZ
P.O. 3178
LA QUINI A. CA 92253
PALM SPRINGS CA 92261
(760)322-3173 c tflfl 2:29
USE OF PERMIT
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PI,I.IibiE ING .FRE -- .10u'WE-k 101-000-41940) S30.00
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31 w
OCT 3 1998
s ; ; Trn't . e s r; ±'ttt t caN .`.f )t, rr c •f 1: 'r ..
; n
LESS PRE -PAID FEES
1.O Oi1
'1'(?1'I1*A ,'1'[+;i MIT F1#',C.S 191111: NOW
;1,3l4,diR
RECEIPT
DATE
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
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 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 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
1
Final
Utility Notice (Perm)
COMMENTS:
-
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
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Received From: /�� /�lif,���
UG' 49411 �s6
Date: AO Z%
Address: 5-26-7-7S Ad 4,01.7,,o
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Account No. � � I Z�j%; �d % All.
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Lots) Z Tract S A wrA
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Service AddressIBJ'
g G.A. Code
❑ Meter(s)
$
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
_
❑ Meter Surcharge
_
nitation Capacity Charge 401
❑ W.S.B.F.C.
❑ 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.
.
❑ Customer Deposit
❑ Other
TOTAL $
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Remarks:
�opy to"
LMAI
Cash t; ?i••s'p
%'.. r Water Service
Check:i''.
Money
_.;
' ,A Cashier
Order
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CVWD-438(11189)
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2502 Morongo Trail
Palm Springs, CA 92264
(760) 327-8859
1- 10-663
VIE I
SOC15 TO
SHIPPED TO
TERMS
dTREETj NO. STATE
STREET NO.
3 Z`76 - ctj
CITY STATE ZIP
CITY STATE ZIP
CUSTOMER ORDER
SVLESMAN
TERMS
DATE
PAYMENT „DUE UPON ,RECEIPT