PLBG (0006-202)- LICENSED CONTRACTOR DECLARATION '
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (comy7nencing with Section 7000) of Division 3 of the Business and
Profegs;,6nals (de, and my License is in full force and effect.
License # Lic. Class j E}
, Exp. Date
-.Date '� Signature of Contract+ r - ���� a,,*
OWNER -BUILDER DECLARATION
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). II
( )'. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). i
() 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. MpT Policy No.
(This section need not be completed if the permit valuation is for $100.00 or, less
(cc)rtldertify 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°37.00 of the Labor
Code, I sh II f rthwith comply with'thAp ,: rovisions.
Date: /C � APRlicaffnt'� X* tA.' ../�'�
ss
Warning Failure' to secure 17Vorkers' 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..
y
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
l the above-mentioned property f'olinspection pur ose/SST
Signature (Owner/Agent )/f� !'v .Date
BUILDING PERMIT PERMIT# z -
DATE VALUATION LOTTRACT
(6/1901(X U .00 t .
JOB SITE APN
ADDRESS wj")5A1]=)A,Nfiff11L)OLk
OWNER CONTRACTOR/DESIGNER/EN (NEER r ,
B'E,T ry C'E:CIa R Y 8 COlhi�I•'RUC`K1014 DRA11 SEP-VICE
63_605 t•�CUTA,NT OSA 82154 TAH.Q. TT'T,c,AA,--R
LA QVINTA CA 92253 INDIO Cly 92201
(760)342-9175 C" 5839
1:
USE OF PERMIT
SEPTIC ASA14 ON r=WE,'s C aNNECT
1tkl.UAT1014
1.850.00 1S
wraWIND COST OF CO STRU•C' 70N
i?k t MB1140 T.TZE 101.000-419.000
RECEIPT
SUB -TOTAL COIAN11 iTC 101 Plf" CPRCK
IVIAL IrFUMM."M711S DUE INOW
DATE BY DATE FINALED JINtPECTOR
INSPECTION RECORD
OPERATION I DATE I INSPECTOR
BUILDING APPROVALS
Set Backs
Fct%ns & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION T DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underqround Conduit
Fixtures '
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice
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 Q7� � _
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underqround Conduit
Fixtures '
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice
COACHELLA VALLEY WATER DISTRICT •.
CASH RECEIPT DETAIL
Received From: f �• ��`(.�%�T Date:
Address: // / ,, // rf ;, /- u . 1 a l 41e / � �07�75 /
Account No. W D (V I 7 ! I [p• (?. �/ Lots) Tract Q (. a rwe Ve4-✓
Service Address -�- �l'C �1 ��l'J 1(%•. i` j % e„�d0 G.A. Code
' ❑ Meter(s)
frP ❑ Service(s)
I ❑ Backflow(s)
` ❑ House Laterals)
❑ Detector Check(s)
❑ Meter Surcharge
x Sanitation Capacity Charge
❑ W.S.B.F.C.
I ❑ Temporary Construction Meter
!`. ❑ Turn on Charge ^
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer.- t
Tract -
❑ .Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
. /•, � • � ` TOTAL $
Remarks: / Oil OL // '�% U /
Phar 760- y3�— ZY/�
�r Copy to: ✓ .� �_
Cash ' Water Service
Check
Money
Order r:. Cashler
CVWD-438 (111AQ1