0306-367 (PLBG)LICENSED CONTRACTOR DECLARATION
1• 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
A.652.1H 4112 RI,", da !A.•t
Date 4s 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, 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 issued. My workers' compensation insurance carrier & policy no. are:
Carrier Sr.ATI,: F`3!�3'� Policy No. • 0-,74-0011310.5-2,003
(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•tfie workers' compensation provisions of Section 3700 of the Labor
Code','1 shall forthwith comply with those provisions. ,' -, -I
Warning: Failure to secure WorkdFs' 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 mentionedproperty for inspection purposes.
l�
Signature (Owner/Agent) °"' Date ! 11 y7 �.
PERMIT PERMITk
.BUILDING t:'4tpC-�:4s5'�
DATE W25,,�0C, VALUATION „ � � LOT TRACT
JOB SITE
ADDRESS 46-945 HA�Tlixxa[A} D Pt�.la�7` S URNF.'
APN
"OWNER
CONTRACTOR / DESIGNER / EN (NEER
}.i C-0i!'CiFtt'"rL LAM,
A I iT lt.�`C?{�L. SERVrCE,.7i: O
46-94161MORILAND PATUAS DR-.-
P, 01 BOX, 3 f331
I.A,,(plyrik CA. !J21253
DE,`ERTHOT 3111 tiGt CA 9`'V,10
1, 6Ci)3c-6675 M111_4 P86
USE OF PERMIT
PLIJIMETIM
WI
,n
%50%06 LS
i
YRRMT jnx aUwlAAA rP-y
11M)MBING F221 SEWER, -101 -000,439-000 SAW
"JUN3.•2003
CITY OF LA QUINTA
FINANCE DEPT. -
EPT.•2US-,TOTAL
2 US -,TOTALCd 3WRMUTCT1011 AND P WAT C41F,'°�:.:
$30.00
TOTAL 11, IT VIM:'S DIEM NOW
� s
RECEIPT
DATE `
BY ^. '
ATFyFI D ? f SPECTOR
r�
A
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor —
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Gas Piping
_
Encapsulation
Gas Test
Appliances
Final
Final -
Utility Notice (Gas)
ELECTRICA APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
111
_ _-_ __ __ _ _ ..._ -,. _„ .... ... ......... .•.. ...... I lift nv. I VV VVV KVUV 1. VL
COACHELLA VALLEY WATER DISTRICT
Received From: !
Redress:
Account• No. Lot(e)
Ssrvlce Address
❑ Meter(s)
❑ Service($)
❑ Backflow(s)
[a House Laterals) .,
4 DetectvrChack(s)
Q�urcharge
zitIti-n Capacity Charge
❑ WS.H•F.C.
A Temporary construction Molar
❑ Turn on Charge
❑ Uncollacted Account -Name
❑ inspection Fee - Tract -
Fee -
❑ Ran Check Fees Wafer 1 Sewer -
Tract-
❑ Hand Paymant - A.D. - Bond.
Assmt.
0 Customer Deposit
❑ other
G..O- Code
S
Remarks:
cash
Check t9
Money
Order
Water Service
Aft
Cashier
CVWD-498 (11189)
JUN -20-2003 FRI 09:57AM ID: PAGE:2
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JUN -20-2003 FRI 09:57AM ID: PAGE:2