PLBG (9806-072)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
04 (Unj Professionals Code, and my License is in full force and effect.
O =) M License # Lic. Class Exp. Date
t-- CY u7LLJ
€tiiI`Kri i:.•i' fi)�31,•n)
oZ � /Date • } Signature of Contractor
J U (D OWNER -BUILDER DECLARATION
HUj 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).
M () I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
p zcc I hereby affirm under penalty of perjury one of the following declarations:
r � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X UJ �: 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.
CD Q U (�' I have and will maintain workers' compensation insurance, as required by
O () Q S ctl n 3700 of the Labor Code, for the performance of the work for which this
11 � Z permit is issued. My workers' compensation insurance carrier & policy no. are:
cb Z) Carrier S'TAT'E FLP1113 Policy No. Uti�6•'lt! {fi)(h5 )l
�a
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' compensation laws of California, and agree that if I should become
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I, shall forthwith comply with those provisions°'
Date: Applicant L '.= r'
Warning: Failure to secure Workers' Co ped on coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
44 application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes. {�
Signature (Owner/Agent) t—•- �.�%1• ` DateJ7
f
BUILDING PERMIT PERMIT# CONTROL#
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DATE VALUATION S f.460.414) LOT TRACT 7891
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OB SITE :Mi-x1{►�s'�'t'`.1^tiiiA ���,151774-223-010
PN irt'2zi-
ADDRESSA
OWNER
CONTRACTOR/DESIGNER/ENGINEER
A 1 1h1At'TA I I?t'14-4
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°�•i-.iltiir'v'�isiiitt �iisiii.�i.iiJ'i
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j,A Q0191'A 022"2,4
1'AI,RI I:)i?SEIt't' VIA 922ol
t7ii01"tdti:li'a3 (111,4 112
USE OF PERMIT
I'l�i1t�1►i
SO, 11%: httAiNIP"ON. '*4W1i1(c
CLoc-D -/tiPry` � IS9 —�
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VALUATION 11,1160A) I.:;
����rrh�;�•r�;� c���E' �� fa:t��;v�►zsiz�rc �•:t�w
t,arn.;IfC
f'i.JWS iNG FETI, -- S$.Wfii� 101-000-419-000 $ V 10)
e
3
S11 ' ll -A1, CON-YrR 1C"!10N AND PI _AN f"IiFC'K.
M
LESS 1111112 4.)AI DI IT. 1"S
$000
JUN 0 8 1998 MRS 011F NOW
S.z All
TOTAL PF R'Ml'f•
RECEIPT
DATE
BY T
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 & 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 �S
Y
FinalUtility 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)
Final
COMMENTS:
. - ECONO SEWER SERVICE, INC.
P. O. Box 192
PALM DESERT, CALIF. 92263.
jam MOME OEM
11887
(619) 346-2793 or 328-7760
TOTAL MATERIALS
CUSTOMER'S ORDER NO.
I PHONE
MECH NIC
HELPER
STARTING DATE
BILL T
ORDER TAKEN BY
ADDRESS r ��
El DAY WORK
CONTRACT
EXTRA
--CITY
JOBB NAME AND LOCATION
JOB PHONE
No one home E) Total amount due Total billing to
Signature for above work. or be mailed after
I hereby acknowledge the satisfactory completion Completion
of the above described work Of work
TOTAL MATERIALS
TOTALLABOR
TAX
DATE COMPLETED
WORK ORDERED BY
TOTAL AMOUNT
/
No one home E) Total amount due Total billing to
Signature for above work. or be mailed after
I hereby acknowledge the satisfactory completion Completion
of the above described work Of work