PLBG (9806-166)LICENSED CONTRACTOR DECLARATION -
U) U
ECLARATIONU)U .I. hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O ch License # Lic. Class Exp. Date
W �i.�7��! L ici G3fi
Z r- VDate �^ ` Signature of Contractorto
o
O�
U C) OWNER -BUILDER DECLARATION
W WW r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
co () I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
ON
M
Q WORKER'S COMPENSATION DECLARATION
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo Cr
r � O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
m � Q pe of
ance of the work for which this permit is issued.
Q V cy,�,)Fvave and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
CC
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
� C) C1.U(I,3* DQN NATIOI" (tlt:it t37S t>s3
Q (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. prov�jsions of Section 3700 of the Labor
Code, I shall fo%,with comply with those Prov sfo`fa _
Applicant f '�`�� A
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
�rVip & 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 f r'nsppec It on�pur
i ignature (Owner/Agent) 4, ��f''� � ' e Date A
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT 1906-11166 TRACT 1
6/113N98 S.1,04d4) oo 1
JOB SITE APN
ADDRESS .rf -885 AVENI M. k�A S t�VI� RE� 173,136-021
OWNER CONTRACTOR/DESIGNER/ENGINEER
PO BOIN 11:111 P 0. M78
ZEA Qj_JIWA CA C0..253 PAI..&I SPRINGS CA 92203
(760)32112_1173 MA > 2229
USE OF PERMIT
5011 Ki MBANL';tt tN, SMER CON N!s( t
VA1.11IWt". NON
100,001-3
N [7,1 �.1A,k,i" P CONN D:• ORI l.\AII�J, `!l'i.i1OC Ro l .�iI41lgal.l4)
PERMIT FEWSUNIMARY
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SUvil'("Y!'AL CONSIRUC110N ANT) PLAN CHECK fon fan
1,E: S TIRE-NAID 111113178 $ faf)
11) VAT, Pl;RhIf'if' # FRN W its, NOW IS30.41141
RECEIPT 1 ! I DATEf r ; \4 BY \ / I DATE FINALED I INSPECTOR
R
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
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
App'ances
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
i
t
Final
Utility Notice (Perm)
Final
COMMENTS:
COACHELLA VALLEY WATER DISTRICT
N r!
• Received From: l%1 /ZG'X C G/2. fk /2 t97�C.C1
� O • � GDate:
a Address: /�. �� L.h
CASH RECEIPT DETAIL W.
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Account No. CCf��Z li / d� ' z
Lot
Lot(s)
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1434 c
L r a Tract
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Service Address% [
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G.A. Code
❑ Meter(s)
�t
Check O {9tJ
Money-
Order
g
❑ Service(s)
CVWD 438 (11189)
❑ Backflow(s)
❑ House Lateral (s)
. ❑ DetectorCheck(s)
Meter Surcharge
��❑
insanitation Capacity Charge
_77f�
ZJ
❑ 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 -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
Z
❑ Other
TOTAL
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Remarks:
p
P27rTle-JIL)
Cash
Water Service
�t
Check O {9tJ
Money-
Order
Cashier
CVWD 438 (11189)
11
(OL — LLC,
INVOICE
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