9806-061 (PLBG)U)
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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 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # ' Lic. Class Exp. Date
ifiu�n, i t +
10/31190
r
Date 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
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 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.
( %t); I have and will maintain workers' compensation insurance, as required by
Sebiibn 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 c;^i`A't7i .8111 1) Policy No.046-"A .0fXWO)
(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 comply4ith those provisions.•
/Date: _ t�-i Applicant, P /fi r
v f
Warning: Failure to secure Workers�Comp ne sation 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`
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �- l Date!
BUILDING PERMIT PERMIT6wom CONTROL#
DATE / VALUATION S1,499 -0f) LOT TRACT 7880
JOB SITE
ADDRESS .1-5-010AVENft)ACARRANZi APN 773-2iij-t ES
OWNER CONTRACTOR/DESIGNER/ENGINEER
110R. t.11041i=iW AWIRRE E?t ON't) SIVIN R SHI'MCE
52-iG0 AVF;NII?t. CARRANZA P.U. I UX 192
1.A (,fI.E1911-A (_'A 142211 VALM DESERT C:A. 9220
If7M13 7M.1346-2793 t_"11E.4 '147
USE OF PERMIT
I'LO 113
;SEPTIC �;i3A%it�i)Ed, SEW-EkCONNiCT
VilT.11A'P'rC N
1;189.00 LS
111.1-INI INt.4 F►.:f., -- 813WFA 101_(X)0-40_0(10) $ 0,00
`�lf13=Et:a4'nT C't)N`E Rt K'f'iC)N
AND E11,+iN ('11lT9 :tit fxl
JUN 0 81998 LESS PRE -PAID FEES $()00
v
'f'4 ►'I•Al, 11"F LIMIT F IM'S 01Esr N43W °S30.4N1
RECEIPTI DATE I By I DATE FINALED I INSPECTOR
—.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
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�/
Sewer Connection T
Pool Cover
Encapsulation
Gas Piping
Gas Test
Ap liances
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
t
C
Final
19ti* Notice (Perm)
COMMENTS:
OR213131431 POLAROIDDb
ECONO SEWER SERVICE, INC.
P. O. Box 192
PALM DESERT, CALIF. 92261
R {
�JO � �OG3a O�D�Q
11861
1619) sod-ciys or sets-iitsu
ORDER���
�
CUSTOMER'S ORDER NO.
PHONE
MEC HA
HELPER
STARTING DAT
DaCOMPLETED WOR DERED BYE , R�
`/f_�
,
TOTALAMOUNT
$
BILL TO
ORDER TAKEN BY
r1/
ADDRESS
dk
DAY WORK
❑ CONTRACT
EXTRA
JOB NAME AND LOCATION
L=
JOB PHONE
PTION OF
�� o one home erClal amount due Todbilling to
Signature � 1or above work: or • be mailed after
I hereby acknowledge the satisfactory completion completion
0 of work
of the above described work.
TOTAL MATERIALS
TOTAL LABOR
of
TAX
DaCOMPLETED WOR DERED BYE , R�
`/f_�
,
TOTALAMOUNT
$
�� o one home erClal amount due Todbilling to
Signature � 1or above work: or • be mailed after
I hereby acknowledge the satisfactory completion completion
0 of work
of the above described work.