9708-109 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04
W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
- t-
oZ r- Date Z �l Signature of Contractor
CCD0�
wU CD OWNER -BUILDER DECLARATION
I— Wd I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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
LO B&P.C. for this reason
N Date Signature of Owner
O0)
Z WORKER'S COMPENSATION DECLARATION
C:, 2 Z I hereby affirm under penalty of perjury one of the following declarations:
0 () 1 have and will maintain a certificate of consent to self -insure for workers'
X W Lr_ compensation, as provided for by Section 3700 of the Labor Code, for the
Oro J Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers' compensation insurance, as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
LO
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No. }
6
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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shallhorthwith comply with those provisions°
Date: Applicant—
Warning
pplicant
Warning: Failure to secure Workers' Compe sation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. +
1. Each person upon whose behalf this application is made & each person at,.,
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemni"Y.,
& hold harmless the City of La Quinta, its officers, agents and employes.
2. Any permit issued as a result of this application becomes null and void'
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize? representatives of this City to enter upon
the above-mentioned property foi inspe tion purposes.
2, WSignature (Owner/Agent) r �` �✓% Date ,
BUILDING PERMIT
PERMITN
it)$. 1409
CONTROL#
57479
DATE hilj.5/97 VALUATION !�S�, iij;,{�{JI LOT
TRACT
e^ -
JOB SITE �) 11 �'1�t.E0�i1 1. tsl�I{i: tyF1'.:�
APN 774-1121-003
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
i• A fzi ljRri'A i+l>111;d!1:t 7 11.1A f1T16PP P➢ Af- I'it"
r.r•t iNu l Ctau:zt) V470, )r T
1 .';•� +: �a ��a. �.•�. r s.f..•+a
-:. • +.+ � •n., is a. �w tu.a♦ t. a.
ii (.f iv,) 1 142
—A QUINI'A. !.'A 9<xS1,
VA UM lit, Sl -,R1' ('A
92121ii
'
USE OF PERMIT
I=i.�it14S
4,`UN�1cIt1�f1%ilfvili�i'f
1•�,J�!.+�i+i i,:e
11IX1tMI11N(1 TtU,-_ `+i5trtER J01-tfi't4}-411,,1 000
S,t!A-Tt`jTlxt+CON FRI1MlaN
A;Vt) j'1;AN M!�;t•'K
r30s7rl
ti=
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
NSPECTION RECORD
OPERATION I DATE I !'rSp'_C T C%
BUILDING APPROVALS
Set Backs I -
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATiON i GRATE I INSPECTOR
MECHANICAL APPROVALS
Underground 0cts I
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
Final
I
I
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
Encapsulation
Gas Pioina
COMMENTS:
Final -
atice tGasj
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Tr.Fnp. Use of Power
Final
Utility Notice (Perm)
ECONO SEWER. SERVICE INC. 760. 347 4978
ECONO SEWER SERVICES
-PALM-DESERT, CA 92261 IVC 8230
• r/Tu11C JLOV r4:! JY4•L/7J
A ODER
V O - 'S OnDER NO.
PHONE 1
PER
STARTING DATE
[MEC
WORK OROEREO Qv
TOTALAMOUNT
ell—gQ
�IIlLL V
ORDER TAKCN
O VliLS�
-� % Ll J L�[� l/v✓ -❑
UAV WORX
_
❑ CONTRACT
❑ EXTRA
ice`
JOB NAME AND LOCATION
JOB PrIONE
PLEASE PAY FROM THIS INVOICE
Signature
❑ No one home ❑ Total amount due Tot'at-billing to
for above work: or be mailed after
completion
I hereby ackaowfedge the satisfactory completion - Of Work
of the above described work.
7
0
P."02
TOTAL MATERIALS
TOTAL LABOR
NO STATEMENT WILL BE MAILED
TAX
OAIF COMP LEr FO
WORK OROEREO Qv
TOTALAMOUNT
Signature
❑ No one home ❑ Total amount due Tot'at-billing to
for above work: or be mailed after
completion
I hereby ackaowfedge the satisfactory completion - Of Work
of the above described work.
7
0
P."02
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
l/ r
Received From_:.
Address: .� 7 C..' C ? Y % 1 ��...� -. rl
Account No. % (11/c= ] o
Service Address
EAMeter(s)
�/ �ServlCe{s)
❑ Backtlow(s)
❑ House Lateral(s)
❑ Detector Check(s)-
❑ Meter Surcharge
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 / Sewer -
Tract--
0 Bond Payment - A.D. - Band_
Assmt.
❑ Customer Deposit
❑ Other
Remarks:
❑Copy to:
Cash I
Check
Money
Order
N2 sa��
Date-�J�`
Tract
G.A. Code
�JI
TOTAL g
WaterServlce
L
Cashier
� �I CVWfI- (11/89)