9706-012 (PLBG)N W
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7WO) of Division 3 of the Business and
Professionals Code, and my License is.in full force and effect.
License# Lic. Class % Exp. Date
'4 -0 1 C-�Sw VX U;tiwev� td/3107
(" 1`Signature of Contracto.
/ OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I ani 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, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section - , B&P.C. for this reason
Date Signature of Owner
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.
ATE IIINID
(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 sofas to become subject to the
workers' compensation laws of California; and agree that if I should become
subjpect to the workers' compensation prrovi ii6ns of'Section 3700 of the. Labor
Code, I shall forthwith comply with those prdvlsl ns.
�.
.Date: �" � Applicant-
Warning:
pplicant 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,idamages 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
fie above-mentioned property for r sp`ectlon purposes.
Z,Zture (Owner/Agerit)`�-�- �✓d �"°%
Date
-
BUILDING PERMIT PERMIT# CONTROL#
706-01112 5 2 G S
DATE 6/4/97 VALUATION C LOT TRACT
JOB SITE
ADDRESS 51-765 AVENIDA CAURAi�lfA
APN
OWNER
CONTRACTOR DESIGNER /ENGINEER
t� n
`DESIGNER
MONSEWERSERVICIE
51-i63.AVFN11�!►.i'.AiiCtt`1N .�i
P.G. BOX 192
t,,A Q:JMA CA. 92253
P.A1.;M DESE U CA. 322.61.
(76Q)340-2743 CKY 347
USE OF PERMIT
SE1`"T11C acr5iai3(�Ai�4f➢:N t'; ttiinfif�tc CO1vMECl.1
VA%.tJfi.'f ICAN 100JAI t, 3
CON'sn'b .,10ra
T.UM8'N0FK, S Wf=CKj0.1.-fW. 4144KJ(1 o.no
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SUBMV.F.M. C.ONS1'(' UCTION AND PIAN CHECK
$30.00 r
i.LSS PRE -PAID FEES
MOd)..
!'e)TAI, PERM. -IT Ffl, D;KIE NOUr
S-Ko0 r .
1
RECEIPT
DATE
BY '
DATE FINALED
INSPECTOR
INSPECTION RECORD
�N
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 Wali Insulation
Condensate Lines
Party Wail Firewall
Exterior Lath
Drywall - IM. 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 Pibg. 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
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:
COACHELLA VALLEY WATER DISTRICT w �' 2
CASH RECEIPT DETAIL
r .
fleceived From: f ! VZK .1 t I tt`� Date:
Address: 1-7(.,-S i xJ a) .C'.AZ, ;U26 Q L I m TA
C
Account No. �� V _ ) 4- G S 6 .0 Lot(s) Tract
Service Address ,- r( G.A. Code
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge c1
��anitation capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge
❑ Uncollected Account -Name--
•
Name❑ Inspection Fee -Tract
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
I TOTAL
Remarks:
$
Remarks: %i/1(J -llly C'U11- 7/�/On /� i -p -
f
]Copy to: /
CashJ G S9 /I psh/tet C��Q UC Water Service
Check �/ 2 l
Money V, Cashier
Order
CVWD-438(11/89)
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