9604-137 (PLBG)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
4 0061 4 i IUiili
Date= AIK Signature of Contractor°��iY='/
9 �
r
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.
(. ) 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,1i s66;E vlyM rkers' compensation insurance carrierl'&1:policy.no. are:
Carrier Policy No.
(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 toythe workers' compensation provisions of Section 3700 of the, Labor
JCode,,l shall forthwith comply with those provisions.'.
Date: �,'�y,{P/!� Applicant—
Warning:
pplicant Warning: Failure to secure Wdrkers' 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 pursuarif to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Ouinta, its officers, agents and employees.
2. Any permitissued 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/Anentdig'G�'�Date.—)1.+
PERMIT# CONTROL#' t
BUILDING PERMIT
9604_,:7 32.0
DATE c J�,(y�lj(*� VALUATION °�' ,tjoQ.'�(;f LOT .. TRACT
JOB SITE
ADDRESS 46-900 HIGHLAND PF1.I..MS
APN .. '71
OWNER
CONTRACTOR / DESIGNER / ENGINEER
468001UGHAifk!ND PALMS l'�}32.
IX3^5, c:;�,�y'it�11v?/Jfia' .
t'PALM,
�w.@-{�.ttf�1't'A. C;A. ,x22.53
(f 7
!-,� LM,;Ot'4S _t�.t CIS 91't)t
fc�3 4 tC� f,:`BIA 342
USE OF PERMIT
SVVIC: Al3Adlo IDOW aENY19Z (_*NNL•.GTif0N
V.AIJ.Llivi., ul-4 Lis
,fI STtLi1N"dri�"!'.�M COS`t'.€3FC;€ONNI'itUCT ON
2,000.410
(Pfi'g tpli)jp�AAg �((4e !, ���spp�{�y��{
RV
I-Itiu4(eiNa f'.f 13' »- +fio1r4.a 10A,-000-4194)00 $30.00
n_ i ;i 1i't3t; r.,'C7N�"'i'1�.�.��'�' 1014 ilND 1'fJ�tRi CF.l C11C
LESS, PRE,-'�At� r a S
S3U.i3b
$0.00
APR 2.6 �,TAL Pi± reg . , FEES.:t��w
1530 R)
' 1996
sy..
RECEIPT.
DATEBY
j .
DATE FINALED
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
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
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 I I
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 4
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
pp liances
6
Final
COMMENTS:
Final /
Utility Notice (Gas)
ELECTRICAL APPROV LS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. rtn,
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
F-CONO SEWER SERVICES.
' P.O. Box 192
PALM DESERT, CALIFORNIA 92261
40M omONREa
47104
PHONE 323-7760 346-2793-5—ATE-07r-(5—RDER
TOTAL MATERIALS
CUSTOMER'S ORDER NO.
PHONE
MECHANIC
'HFLPii9
STATMfqG DATE
ILL TO
ORDER TAKEN BY
A DR
WORK ORDERED BY
DAY WORK
CONTRACT
EXTRA
12 2
B NAI O
JOB PHONE
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
lea% PER MONTH CHARGE AFTER 30 DAYS
Signature
PROMM 258-7 ses Inc
Cmton M= 01171.
❑ No one home ❑ Total amount due
for above work. or
I hereby acknowledge the satisfactory completion •
of the above described work
0 Total billing to
be mailed after
Completion
of work
TOTAL MATERIALS
TOTAL LABOR
PLEASE PAY FROM THIS INVOI-E
NO STATEMENT WILL BE MAILED -
TAX
DATE COMPLETED
WORK ORDERED BY
TOTALAMOUNT
$
Signature
PROMM 258-7 ses Inc
Cmton M= 01171.
❑ No one home ❑ Total amount due
for above work. or
I hereby acknowledge the satisfactory completion •
of the above described work
0 Total billing to
be mailed after
Completion
of work