0105-155 (PLBG)LICENSED CONTRACTOR DECLARATION.
I,hereby affirm under penalty of perjury that I am licensed under provisions of
:,-,Chapfer_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
:OWNER -BUILDER DECLAFATION
I hereby affirm under penalty of perjury that.l 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 ) I,, as owner of the property, am exclusively contracting with licensed
contractors to construct the project,(Sec. 7044, Business & Professionals.
Code): t
( y I am e%em`pt under Section B&P.C.J6e,,this,reaso r
Date 4 i/ Il��"` f Signature ,of Owner G�A��J:!-�.— J- e ^—
�r�= .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 Js issried.`Ay' workers' compensation insurance carrier,'& policy no. are:
Garner- • Policy No.
ys.`i r '
(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,
:Iahalf riot 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 L.spall ff-rthwith comply with those provisions
Date. Applicant
Warning:. Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions, and restrictions set forth on his
application.
1. Each person upon whose behalf this application is'made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this'applicaton agrees to, & shall, indemnify
& hold harmless the City of 'La Quinta, -its officers, agents and employees.'
2. Any. permit issued -as a result of this application becomes null and void if
work is `not nommen. ce'd within 180 days from hate of issuance of such
permit, orcessation of work for 1.80 days°will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature,(Owner/ADate?
BUILDINGPERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
,,
;
`
yy'-����yy•��••������, 7y'
AJXM.S'k1'JATd dGi.f:A BROW
.+'��yy��p'��j pT►'+�j' yy'y''��"J
.e �.d'W$VY..Ri. iJ'6I P. aii1JJ++L1..; Ff..ar * .• ..
51,850 A Y1?,M Jig MOM ZZ
CA 922.5s
,
USE OF PERMIT
�.�
�y j� qq yy�� appp�y1. ``��
V f►LUXr10,H f,,.
l•TY, OF L-A OUINTA
x,-
HkAkE DEPT,
:*T51MA .ED i OVX''lA8• b47.LVS7.4`R C.A.JIiAA.Y
x?' ECJ 47iJ' t
PLUMIM40 FEE SWER 103 _000-4431 9-000 $30.00
,
ca
:STM -TOTAL CONW1',EiUMICK Mb PLAN M;Iir n,
sl o. w t
II= PRD2PAU'.� b' `7
$0.00
TOTAL mAlft Yms Dur. now
= 5k
RECEIPT
DATE/,By
DATE FINALED
INSPECTOR �,
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
i 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 I 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 _ _�J
Sewer Connection =�(�—
Gas Piping
Pool Cover
Encapsulation
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
Final
Utility Notice (Perm)
COMMENTS:
F,
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CVWq 43 - 8(1 9)
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COACHELLA VALLEY WATER DISTRICT i
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CASH RECEIPT DETAIL
Q�
08
Received From:((�-�•��- �---
�' �, 1_
4f 316381
I
Date'
Address: f " 1 �) i f
.1_c �.�.�
Account No. r
�.... _ f . _
Lot(s)
Tract
�•A�.,�,
Service Address-�� -�•- t ' <<.
G.A. Code
❑ Meter(s)
$
❑ Service(s)
❑ Backflow(s)
❑ House Laterals)
❑ Detector Check(s)
❑ Meter Surcharge
•,2'�SanitationCapacity Charge
❑ 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 -
' n
❑ Bond Payment - A.D. - Bond
.
,�
Assmt.
7
❑ Customer Deposit
❑ Other
j
1 i _
TOTAL $
Remarks: t\_l_'i-..;;
f'•.. �'� tl t ti�iti`
to: f +.t -3 i
_..00opy
1 1< co
Cash 'C
a..%." l
Check
`, 5•
Water Service,
n ti s n �^.-
F,
rc ,: oneY =? Cashier �
r: Order z':
CVWq 43 - 8(1 9)
l nA 118
l