PLBG (9605-113)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
CrApter 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
$37.133 A 4 � :�f31NO
,,Date ��-� Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) 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 M wo kers' compensation insurance cam r • &, olicy no. are:
t,.wx t Y1F,�1 e irBr ).up
Carrier Policy No.
(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 offeallfor In a, and agree that if I:should become
subject to the workers' compesation provisions of Section 3700 of the Labor
Code,hal fortiwtii)i h comply with tht se pro vis' S.
Date: �, Applicant � L
Warning: Failure to secure or ers' 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 haveread th�'s-appl'`^ic on 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 representati�(es of this City to enter upon
the above-mentioned property'for inspection purposes. f f
Signature (Owner/Agent) Date r Z 3/�
BUILDINGPERMIT PERMIT# CONTROL#
L (V=1
1L�'
960.5-113 3365
DATE VALUATION LOT . TRACT
5/21196 sl,!)llil w
JOB SITE
APN
ADDRESS .52-701 AVENIDA liiL.�:fli(tZA
773-302-022
OWNER
CONTRACTOR/DESIGNER/ENGINEER
BILIN C & JO R ATC LII:Ir
TFfiJmuln" 01C.
.52701 AVI:.NIWi KIHN1504 .
51 -GOO EISENH:OiWI.MDR.
IN[NO 4:'-A 922W
LA QTJII<rl'A CA 9225A
i�.ttl�)?7�3_R ��
lti1�J)Sf5+1-I CRUZ 21;26
USE OF PERMIT
€'1,i 1A9F3itvt�
SH-PTIC ABA:NDC)NlS.EWIN C'ONNEC3'ION
Vi%L IATioN t,l)UU;IM) i's
R'NTIMAILD CONT OF CONS'iRUC"RON
3,0iin.Iiif
I'l+:Itlt4l'l' �'1+:ir; �111�'I�'►Atti'
");,1 N011Nt:1 F'l%— SRV111 R 101-000-419 4)(9) S t).fKt
SUIS -'f ;t'1'AL CONS'lTtUC'IION A NS3 P.C.,1 N CIJPCK
$30.00
(� LESS PRE -PA II'3FEES
CO
$0.00
fYjA Y C\� " 1996
I E3
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE 7
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Bachs
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 Wali 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 I
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 4
Encapsulation
Gas Piping
Gas Test
Ap li
Final
17
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:
-
Ps * 66.1ti I
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
L Received From:
'7
Add=
7
.:
Account
Lolls)
Service Address
0 Mater(s)
Cash
Check
0 Service(s)
0 Backflow(s)
Money
Order
0 House Laterals)
0 Detector Check(s)
Cashle
0 Meter Surcharge
&.1.9.1-lon Capacity Charge
0 W.S.B.F.C.
•
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee-Tract-
ee-Tract-
..
Fee -
0 Plan Check Fees Water I Sewer -
Tract -
•
0 Bond Payment -'A-D. --Bond
Ps * 66.1ti I
0 Customer Deposit
0 Door
Remarks:
QA
TOTAL S
OCOPY to:
Cash
Check
Water Service
Money
Order
Cashle
'tit ,r,,
2502 Morongo Trail
Palm Springs, CA 92264
(619)327-8859
N2 10249
SOLD
TO
TERMS
SHIPPED TO
STREET NO, fp
ST,ATE �J
STREET NO.
CITY
STATE OF
ZIP
CITY STATE zip
CUSTOMER ORDER /
SAIJJ`E�SM-A-N---
TERMS
DATEr [7
Al
PAYMENT DUE UPON RECEIPT