9806-224 (PLBG)LICENSED CONTRACTOR DECLARATION
"1 hereby 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
ckt'4 W Professionals Code, and my License is in full force and effect.
O ch License #% Lic. Class ✓�E�x+p.. Date
Z roll e~�Q 1-' ""!7Signature of Contractor,,,, ��
c�D 0
r- I.—C:) OWNER -BUILDER DECLARATION
J
.W Wd r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
<'') () I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
0
0)
Z
WORKER'S COMPENSATION DECLARATION
C:) :EZ •1 hereby affirm under penalty of perjury one of the following declarations:
p () 1 have and will maintain a certificate of consent to self -insure for workers'
X w LL compensation, as provided for by Section 3700 of the Labor Code, for the
m� Q perform, ance of the work for which this permit is issued.
Q C) / i.�) I have and will maintain workers' compensation insurance, as required by
Q C) Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
? Z Carer Policy No.
Ob d 31 W`l`i's I'ilivD «Li��7••t?U1•�:('>
Q (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.
Date: Applicant
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. i t
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 insppeect�ion.purposes. �
Signature (Owner/Agent)r {y` --' Date/_ " `�
i
BUILDINGPERMIT
PERMIT#
CONTROL#
DATE VALUATION LOT
tili3tti4 TRACT
A O O
S i,,.s(111.410
Q
JOB SITE
ADDRESS 53-20AVEWIDr� �..kLRI�F�. 7A
7774-051-010
OWNER
CONTRACTOR / DESIGNER / ENGINEER
fiDE& 11r,.CK,Y llOWERY
'MI STAR CONS` RUC'1'tON
'53200 AVBN11:►A C'ARRANZA.
31130 CAN (31,1`s�'V00D #7
LA QUID A CA 42253
C' ri1'f3ts`DR.AL. CTrY VA
9P6 3,11
(760)V II -0". ,R CRLX
701
USE OF PERMIT
t'i.1.Uh14:C
415t�1it" ABAN.Ut.3;V, SI;i.Vvi%K CONNiO-f.
V AL(F►i'1'K14
31.51041 (110 41.3
1tFS1'iMATED iYaST
OV C'ONSTRUC.710N
J.-sikoxi3
H? WO ftfif, SOMMARV
111.11MBINt) FVIE -- SEWER 1()1 -(1(I() -41Q_00) $31).0o
e i
Rx'*1"ON
`K
AND AN (-TTE
1, to no
1 XS8 1'1W. i�M0 VIT. S
4:0 00
JUN 3 0 �ggg
f0TAL PERNIOT FU1r,% r)UE' N0W
.m! 3 y LA ci�?$��
s�d4.
RECEIPT
DATE
'V
1
DATE FINALED
INSPECTOR
F..
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 Lateral
Pool Cover
Sewer Connection
/
Encapsulation
Gas Piping
Gas Test
Appliances
If
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
C!
fl -
Final Final
Utility Notice (Perm)
inal
COMMENTS:
.. V F" u
COACHELLA VALLEY WATER DISTRICT'
CASH RECEIPT DETAIL `��(�
Received F
Address:
Account No. �1�1 Lc f f 7 y •-Lot(s) Tract
Service Address S7 O'e-) G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge n /�
Zi -Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee'- Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL
Remarks:
QCopy to:
Water Service
Cashier
J
9YWD-43e („189)
V
Cash - (11.
/
!
Check
Money
Order
.,
Water Service
Cashier
J
9YWD-43e („189)
V
R SERVICE, INC.
P. 0. Box 192
PALM DESERT, CALIF. 92261
K OMMEM
11902
ION OF
(619) 346-2793 or 328.7760
,I -
CUSTOMER'S ORDER NO.
PHONE
ME NIC
I.AEPER
STARTING ATE
DATE COMPLETED
WORK ORDERED BY
TOTAL AMOUNT
.�
_)
L TO
^�
�✓ r 1
ORDER TAKEN BY
AD RES
S—
C/
Ej DAY WORK
CONTRACT
CITY
EXTRA
JOB NIA1917E
AND LOCA
JOB PHONE
ION OF
Signature
No one home — dotal amount due
for above work: or
I hereby acknowledge the satisfactory completion
-1
of:tbe' abov8 descrl
jW -
Total billing to
be mailed after
completion
of work
TOTAL MATERIALS
TOTALLABOR
TAX
DATE COMPLETED
WORK ORDERED BY
TOTAL AMOUNT
.�
_)
Signature
No one home — dotal amount due
for above work: or
I hereby acknowledge the satisfactory completion
-1
of:tbe' abov8 descrl
jW -
Total billing to
be mailed after
completion
of work