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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
7,it`s 159 0142 � _ _ V29/00
,pate - E "Nsignature of Contractor `
S ✓� it ,
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.
(4) 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:
Cartier Policy No.
WLE)EX NAME TNS. NIWC�443066-W
(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 provisions. ^
4ate: ! - 1 ? t rLf Applicant / ..,. ' ,✓`r "
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
& 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) f '•�' _ Date
BUILDING PERMIT PERMIT# 5
DATE VALUATION LOT TRACT
J011SITE APN
ADDRESS 552-5,47VrVADA CARiNZA 77X291 -ow
OWNER CONTRACTOR / DESIGNER / ENGINEER
K09,,ffiRT01DAV.kL S . ECONO SE"W ,R, SEB.`1ICE
52580 AVENID"A. C;,Ei.PMANZF+ 84035 C'tiB1=19 IW . NDIO. CA 92241
LA QUIZ I A CA 92253 PALM DI-SEIM' CA 92261
(760)M6-2793 CSE..# 343
USE OF PERMIT
S>:t'U; ABW)014, S� AT5R CC7t*FECVt' (1,0 -MOD PA,0Ji s'"E 998-20)
CC3NTIRACT iA11{7L IN r 1,500.00 LS
1110 .iiv V1 I+MIX SUMMARY
e XIV.113IN G F� iE -- REWER 101-000-419-000 x30.00
SO-A-'TT)TA(,, CONS'YRI.IG"I'CON AND PLAN e"R"ff:CK
LESS PRE -PAID fRES
RECEIPT I DATE I BY ' ,t'_/ I DATE FINALED J INSPECTOR
T"30 no
T-0100
R
A
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
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 Lateralti
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:
ECONO SEWER SERVICES
P.O. BOX 192 -
PALM DESERT, CA -92261
-% f. '77C„
JOB WORK ORDER
1
1076�p
%IWW/ J# %F-GI7.0 \i vv/ If WW
TOTAL MATERIALS
DATE OF ORDER
FAX (760) 347-4978
TOTALLABOR
✓ .,�
CUSTOMER'S ORDER NO.
PHONE
MEC DII
ELPER
STARTING Q4FE
f
DATE COMPLETED
WORK ORDERED BY
TOTAL'AMOU
BILL TO
amount dueTotal billing to
ORDER TAKEN. BY
,L
ADDR SS
❑ DAY WORK
El CONTRACT
CI
❑ EXTRA
JOB NAME AND LOCATION
JOB PHONE
DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
11/2% PER MONTH CHARGE AFTER 30 DAYS.
Signature for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
be mailed after
completion
of work
TOTAL MATERIALS
TOTALLABOR
PLEASE PAY FROM THIS INVOICE.
NO STATEMENT WILL BE MAILED.
TAX
f
DATE COMPLETED
WORK ORDERED BY
TOTAL'AMOU
❑ No one home ❑Total
amount dueTotal billing to
Signature for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
be mailed after
completion
of work