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l,here,bMffirm 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
jy Iif�t�airl C'Z 105107
r,D/ate C� Signature of Contract
OWNER -BUILDER DECLARA ION
I hereby affirm under penalty of perjury that I am eze�pt 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.
tom) 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:issuepd..My,workers' compensation insurance carrier,;&.policy no. are:
Carrier ts.f'4�rvU Policy No. t.s,:ctr -9
(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.prUry
ons of Section 3700 of the Labor
Code, I shall forthwith comply with thoseisions.
/ate: ��I� Applicant— __
Warning: Failure to secure Workers' Coensation coverage is unlawful and
shall subject an employer to criminal penalt es and civil fines up to $100,000, in
addition to the cost of compensation, darnates 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 four'' pection purposes.
ignature (Owner/Agent) Date.2.:�
BUILDING PERMIT
DATE VALUATION LOT
6119/96
�90iD.0t3
TRACT 3532
JOB SITE APN
ADDRESS 52
705 AVEN.I DA { A1iRA1VVA
OWNER CONTRACTOR/DESIGNER/ENGINEER
EMU., , MOPUTCAGE CORP ECONO S1:b TU1, S1'R'M
52 705 AV1a.NI DA CARR.A.NZA 53443~ CABAZON RD,
LA t'20W'A CA 924,53 PALM i'1UNER {' CS '4?261
(6Iq)346.2'�3 C`13i.f# 3q!
USE OF PERMIT
SEWER HOOK -LIP
C.Y.) s RAA i t\14pt)UN i
960,w i's
(IM I' OF (:(y�t`S'1"ki r�"D'ial�
I'k;IRMIT FEE1iilj1 MARY
ly5.i!M011W) V41- --SEWER 101-000419-000 $;fit?.00
SUB "I'0'3.11. Ct:>Nr;,'�'PWC"%tON AND PLAN C1113C15
L1,S8 I'ft E -1)A11) 1. ET
Juiv
RECEIPT DATE BY DATE FINALED JINSPECTOR
900.00
SAW
.to.00
,530.4.41!
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
3 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
I
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
Neater 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
COMMENTS:
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)
52_71C_ -)T
Info dzk-4/JZA
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: "I
fj
Address:
Account No.
Service Address
• Meter(s)
• Service(s)
• Backflow(s)
• House Lateral(s)
• Detector Check(s)
• MeterSurcharge
lb -Sanitation Capacity Charge
• W.S.B.F.C.
• Temporary Construction Meter
0 Turn on Charge
• Uncollected Account - Name
• Inspection Fee - Tract -
Fee -
• Plan Check Fees Water / Sewer -
Tract -
• Bond Payment - A.D. --Bond
Assmt.
• Customer Deposit
• Other—
Remarks:
S;4 6i'
Tract—
G.A. Code
TOTAL
$
0 COPY to:
Cash f,Water Service
Check 1 "r
Money Cashier
Order
CVWD-438 (11189)
ECONO SEWER SERVICES
P.O. Box 192 r.
PALM DESERT, CALIFORNIA 92261
AM Wmv OEM
47258
'HONE 328-//b0 3443-2/93
TOTAL MATERIALS
A
77
CUSTOMER'S ORDER NO.
PHONE
ER
STAR
DATBILL
TAX
=ANI(3�M
WORK ORDERED BY
T
$
ORDER TAKEN BY
DDRESS
❑ DAY WORK
CONTRACT
CITY
EXTRA
J N ME A7D CATION
V ,
JJOPHONIF-
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
1%% PER MONTH CHARGE AFTER 30 DAYS
one omeTotal amount due L] Total billing to
Signature or a ove work: or be mailed after
PROGIICf 25&2Int. I hereby acknowledge the satisfactory completion Of completion
work
Gmtw Mm 0191. of the above described work
r,
TOTAL MATERIALS
TOTALLABOR
AV FF Mr.
NO STATEMENT WILL BE MAILED
TAX
DATE COMPLETED
WORK ORDERED BY
TOTALAMOUNT
$
one omeTotal amount due L] Total billing to
Signature or a ove work: or be mailed after
PROGIICf 25&2Int. I hereby acknowledge the satisfactory completion Of completion
work
Gmtw Mm 0191. of the above described work
r,