PLBG (9806-067)S:= LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of.
Chapter 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 Exp. Date
,/Date Signature of Contractor."
iv
OWNER -BUILDER DECLARATIO
I hereby affirm under penalty of perjury that I am exempt from the Contractor'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 S1r.11V01%UM) Policy No. M6 9& 0101,900
(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 shall forthwith comply with, those provisions.
,,Date: z- /_f_')Applicantl,
Warning: Failure to secure Workers' C ppensation coverage is unlawful and
shall subject an employer to criminal pehalties 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 upon
the above-mentioned property for inspection purposes. ,
1 �' ✓ �Z,�.... /, <.,
rSignature (Owner/Agent) 1 � �'Date ~
BPERMIT# °DNTR°`#
9:tf.f•6-illi,')'
BUILDING PERMIT
DATE t VALUATION °�,� LOT TRACT -7886 eQQ6
r,
JOB sIT 52-691 AWa'NI a'►A E%IAL'N DOZA
APN 7i i jt I ,i
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
52-69! A VED41 . . D313074%.
P.O. BOX192
LA QUifINi A CA 92253
PALM, DESERT CA 92261
CBI,-# 342
USE OF PERMIT
PLUMB
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P►..UM131; O FIE., -- S.fu'"DI.
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t '... LESS PRIE-F AID .i'.I:aifs. c)
$0.00
JUN 0 S 1993 :�s�TAt" 41FRMff ��ECS Oil 0;NOW
0.00
RECEIPT
DATE
BYr
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
,Set Backs
Underground Ducts
Forms 8 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Ap liances
_
Final1
Utility Notice (Gas) / a f,
ELECTRICAL APPROV LS
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
r
Final
Utility Notice (Perm)
Final
COMMENTS:
P, ECONO;SEWER SERVICE, INC.
P. O. Box 192
PALM DESERT, CALIF. 92261
jam RM OMM
12091
(bl9) 34b-2793 or 32f3-7760
TOTAL MATERIALS
77?1`9
CUSTOMER'S ORDER NO.
PHONE
HELPER
STARTING DATE
DATE COMPLETED
WORK ORDERED BY
�NNIC/n
$
BILL TO
ORDER TAKEN BY
A SS
DAY WORK
CI
E] CONTRACT
EXTRA
JOB NAME AND LOCATION
JOB PHONE
'
TOTAL MATERIALS
TOTALLABOR
TAX
lop
DATE COMPLETED
WORK ORDERED BY
TOTALAMOUNT
$
Signature
E] No one home Ej Total amount due
for'above work: or
I hereby acknowledge the satisfactory completion
! of the above described work
Total billing to
be mailed after
completion
of work
ECONO SEWER SERVICE INC.
ECONO SEWEii SERVICES INC.
P.O. Uox 192
PALIA DESERT, CALIF. 92261
8.18-98
HOMEOWNER:
52-691 AVE MENDOZA
LA QUINTA, CA
760 347 4978
The wall has been satisfactorly fix in the
area of the sewer connect,If you have any
matching paint we will touch up that area.
If in agreement please sign & daLe.
THANK YOU.
(619) 346-2793 or 328.7760
P. 02
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