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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury tliat 1 am licensed under provisions of
Chapter 9 (commend ng, with Section 7000) of Division 3 of the Business and
Professi,onals_Cooe; and my License is in full force and effect.
License # Lic. Class Exp. Date
5214 Cdr: f �� OV2812C
ate J Signature of Contractor'✓'
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 1
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).
( ) I am exempt under Section , B&P.C. for this reason
Date Signatu4 of Owner
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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• Policy No.
STAT E FOND 046-00-M520
(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'prdvisy ns.
Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful ande,
shall subject an employer to. criminal penalties and civil fines up to $100,000, ink
addition to the cost of compensation, damages as provided for in Section 3708
of the Labor Code, interest and attorney's fees. -4
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. J', %
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 . bove-mentioned property for innsppectio Vurposes.
/ignature (Owner/Agent) �" " '""" " Date 4
��`,Y^:, :BUILDING PERMIT
PERMIT# • - ` "�'� "-� —-""--••-_
_ ,.n ,
DATE ' � is 'a' VALUATION LOT
: 0101_3L7 TRACT
JOB SITE
APN
ADDRESS
51-520.A'JEMA ClCFX,t NZA
-
OWNER
CONTRACTOR/DESIGNER/EN (NEER.
ROMPI
•.. -�S�J""l,Y y+: d'P-IS°.x*AS..43,AY7��� t
�• �,.�1V1� l�a�
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XJ2£.�'la'CC9'.i 5'P�3?fii<s X"„A 92240(7C:Uj329.,61r15
Cry'
.fir :0386
L E OF PERMIT
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`a"f:�'P°CP(:.lk.d A14T) )N ' ak'W1. R HOOK -Up
VALUATION
i
51ii14i8 i COST 0r�C.'C"+i�u ����SC� C��
1,5(40)
JAN 2 9 2001
Y UL' L A Cluffil
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�•7•�tr'�{� p�i�
.K7t§••`.[r3%.R�3',. C0WrnZUC 10N ARD Y11.Awp3�+ C�3(EC:[`t�,
$30,00
�¢
0
$01,0
'10'S:eA.L F:[t."1r MY MKS DUE NOW
I �o.w
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RECEIPT
DATE
BY /I
D AL
D
INSPECTOR
I
.`1.
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Fonts & Footings
Ducts
Slab'' Grade
Retum-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 Wali 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
Water Piping
/
3��(
Heater Final
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
Final
Finale'/ 5�
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:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL'
Received From:
Address:
';tccountlslo. Yl %Lot(s)
Service Address 271�0
0 Meter(s)
• Service(s)
• Backflow(s)
xro n2wqa
AI
G.A. Code
• HouseLateral(s)
• Detector Check(s)
0 Meter Surcharge
0,SEuii,iat,ion Capacity Charge
0 W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 inspection Fee - Tract -
Fee -
0 Plan Check Fees Water I Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
0 Other
TOTAL $
Remarks:
OGOPY, to:
Cash %Water Service
Check
Moneyr
Order
CVWD-438 (11189)
Cashle