PLBG (9702-062)LICF..NSED CONTRACTOR DECLARATION
heretr.y, afff,'rn'"under penalty of perjury that I am licensed under provisions of
+iapter 9;(commencing with Section 7000) of Division 3 of the Business and
rofessionals Code, and my License is in full force and effect. _
License # Lic. Class Exp. Date
LLl
CC
Z r1_ Date Signature of Contractor
O�
OWNER -BUILDER DECLARATION
W d 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).
�
(f) I am exempt under Section , B&P.C. for this reason rR i
O N Aate 7 '�7 I % Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q CJ ( )' I have and will maintain workers' compensation insurance, as required by
Ij U QSection 3700 of the Labor Code, for the performance of the work for which this
(3� 0 H permit is issued. My workers' compensation insurance carrier & policy no. are:
't Z Cartier Policy No.
ob 5
O(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: %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 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
vs,
e above-mentioned property for inspection purposes.
gnature (Owner/Agent) v / L-11- -. Date ' 7 A/11
PERMIT #
BUILDING PERMIT
CONTROL #
4736
DATE Zn, f' %9' VALUATION 5-715 00 LOT TRACT
JOB ADDRESS 5146"!-.E�N''�ir�:t�: A �'VI�Vf,.RRO
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
RUBEN, SCRVIN
Citi N.L.N.3 BUILDER
45-788 GrvkcE
tAi))iC� CA 92201
l.'
iMIli`r
USE OF PERMIT
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15100
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TOTAL PFXMFfYFTkX)UVe, NOW
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS I MECHANICAL APPROVALS
' Set Backs
Forms & Fc
Slab Grade
7 Steel
Roof Deck
O.K. to Wr.
Framing
Insulation
Ducts
Return Air
Combustion Air
F.A.U.
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
nrvwall _ int i ath
POOLS - SPAS
BLOCKWALL APPROVALS
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
Gas Test
COMMENTS:
Notice
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Tema. Use of Power
Notice
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: 1. (d / l I UI" 1 "1 / [� / L c.C4.1 / ] 0—
Address: (Ct c i l O
Account No. 6' Q&
0 / //��7 n " 3 /Lot(s)
Service Address 51- _ Cl. u .) l • LL Ua (/R r o
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral (s)
❑ Detector Check(s)
❑ Meter Surcharge % l
xSanitation Capacity Charge -�- �,• �-�
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
Remarks:
W 5992
TOTAL
❑Copy to:
Cash
Water Service
Check
;
Cashier -^; 'N
.
Money
Order
CVWD-438(11/89)