0012-206 (PLBG)LICENSED CONTRACTOR DECLARATION
U) nrI he affirm under penalty of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
(V w' Professionals Code, and my License is in'full force and effect.
=) M License # Lic. Class r. Exp. Date f
CY
A T3
0 0 Date l^• � Signature of Contractor
J U � OWNER -BUILDER DECLARATION
HW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N 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). .. ,
C0 () I am exempt under Section B&P.C. for this reason
LO
N Date Signature of Owner
O cel
rn
d Z WORKER'S COMPENSATION, DECLARATION
C:, 2 Z I hereby affirm under penalty of perjury one of the following declarations:
1-2 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
O J Q performance of the work. for which this permit is issued.
C3 Q U °) I have and will maintain workers' compensation insurance, as required by
O Sectton 3700 of the Labor Code, for the performance of the work for which this
U
rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
z Carrier Policy No.
ao 5 ':3'I`ATZ FUND 94a•Qt�•�OJ��9
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J (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
supject to the workers' compensation provisions of Section 3700..6f,the Labor
Code, I shall forthwith comply witht those provisions
mate: 11 r �A A-0 Applicant l!f `� ir'�-v'r>1�' 1 f r' y
v Warning: Failure to secure Workers' Compensationcoverage 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'C'-ity to enter upon
thesabove-mentioned property for
inspection, purposes. %
VSlgnature (Owner/Agen(-- �7• %�� = * D to /2 / V
BUILDING PERMIT PERMIT J/
DATE VALUATION LOT lr+l��yisl TRACT
JOB SITE
APN
ADDRESS
51-970,A►VY.KD.A CARR&NZA.
'7WXIG3-01.1.
OWNER
CONTRACTOR/DESIGNER/ENGINEER '
MR. AND MRS. E -11)W RD C ARLOS
.i FNBOER Js' (MITMURG & COW
`J)45?70 AVEM31A C`ARRAJ,l;r-,.F�. '
0-175 B�.IIYOS COUTRY
LAQUDITA,. CIA 9 253
C. fUMt7'.#t}� iilY CA 92234
f,-760)3P"J�22i�® C 7 x 3577
USE OF PERMIT
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MOM MIR SUMMARY,
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'T LTB-J'OCAI.,(.401•aMV0CIC"•l109MMPLAN tJ.i"TF+.+CIC
$3,00
LOS P3M-PAH) i MS
$0.00
TOM PZ:IM I @`IES DUE ROW
RECEIPT
DATE,.�
BYE
DATE FINALED
INSPECTOR
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
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
Sewer Connection - , Q ( $?
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final L.2 -0/
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)
PUMPINGANC. .
fP g. Box 2419- ,
CATHEDRAL CITY, CALIFORNfa 92235-2448
t%ant Zan_7AAQ
JOB INVOICE
� - 1
QUANT.
1. ��� ��� ��
(760) 321- 7448
PRICE
AMOUNT
CUSTOMER'S ORDER NO
DATE ORDERED
-
�6cG
Pumping Fee per 1000 gal.
1 j ( • r
ORDER TAKEN BY
DATE PROMISED ;j A.M.
U
P.M.
BILL T
PHONE
Out of Area Fee
ADDRESS
ME( ffIC
-1lJda%
CITY
HELPER
J NAME AND LOCATIO
i
C}-D'AY WORK
Size System:
F1 CONTRACT
I1 EXTRA
E SCRIPTION OF WO
-
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
�6cG
Pumping Fee per 1000 gal.
e--
U
Dumping Fee per 1000 gal. )C
S
Out of Area Fee
Locating / Opening Fee (per hour)
/
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR AMOUNT
TOTAL
MATERIALS
MECHANICS Q
HELPERS Q
TOTAL
LABOR
r�
I hereby ac edge 'fie satisfactoP$ / - TOIAL MBOR
comp) of the,d 4e describecywor
TAX
S NATO 1
•� J f �•-,
��1'-.�f
DAT COMPLETED
TOTAL
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