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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
17333 A B 8/31/00
y
ate �T � ��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
( ) 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.
()6 1 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:
Carrier Policy No.
5TAX I'�11 D 110-123.1-98
(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 Inmploy any person in any manner so as to become subject to the
worker compensation laws of California, and agree that if I should become
subject to the workers' compepsatfon_grovisions of Section 3700 of the Labor
2 dde, h;311 �o�th j h comply withtthdse provisions.
Date. G 1 Applicant t_=_
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 inspectionpurposes.
ignature (Owner/Agent) �" Y Datel Z +
BUILDING PERMIT PERMIT#
S-1
DATE VALUATION LOTTRACT
�I.'Stit1.(iC1
(- -
ADDRESS 553-81,'5 1�'E' EN_IDA CARRAW k JOB SITE
APN _
OWNER
CONTRACTOR / DESIGNER / ENGINEER
!MWEN ARRAIIAM
Ntl;MBUI, WC.
53-813 A ENIDA i:AUANZA
P.O. BOX' 1555
LA QIJ19TA CA. 9 2253
LA C?WNTA CA. 9225 t
(760)340-27215 C110f 2526
USE OF PERMIT
ri.,unt�l�Nc;;
SHIMIC AFfANDC.1rtUT.'''14T AbTs .iEWrAR. CORNEC t ION
VAI.'UATlf:?iN 1,5}.011 LS
$a,Si F', 1%1A T ED C'0 Yar 0r C01, C IT
1115619.00
PERMIT r C, E StCiMhURV
K1JMH1NU f HE -- £ti:W1's12 101-4M)-419-000
SI T IM—Yf'At, C ONISTRUKK''('iON A ND PT AN t;'1l4r_- K
s, ttl lNl
t,r.s 11RE-PAID tT-C.":
Wool
TOTAL P>r"RMIT FE S 0V N W
$30.00
RE QIP ;` i
ATE
BY %
DATE FIAAL56
INSPECTOR
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
0. 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
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 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
Smoke Detectors
Temp: Use of Power
Final
Utility•Notice.(Perm)
IIIIIIE
SANCO -
PUMPING SERVICE
.( v
2502 Morongo -Trail
Palm Springs, CA 92264
(760) 327-8859
`1'0637
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CUSTOM R ORD R
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TERMS
SHIPPED TO
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STREET NO.
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PAYMENT DUE UPON RECEIPT
. T . _ * �y,Fp ,.�•r�ne. r . .. `:^Lr�»�-z•"-vrj_�r+h-ir •sem= i+:w-r.:r.•.+-3'_'.
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:
Address:
Account No. Lr -(19 ���� 66 2 �'!
)
Lot(s)
Service Address
❑ Meter(s)
Remarks: ILI-
❑ Service(s)
]Copy to: ,- u�
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
�2
O Meter Surcharge
❑ Sanitation Capacity Charge
J W.S.B.F.C.
r_
J5
❑ Temporary Construction Meter
Order
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Denosit
❑ Other
TOTAL
$ 79Z,-0
Remarks: ILI-
]Copy to: ,- u�
Cash
Check
�2
Water Service
Money
Cashier—
Order
CVWD-d38 (11/89)