9901-056 (PLBG)JLICENSED 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
i
IV) 150 C-1
Signature of Contract r,
OWNER -BUILDER DECLARATION
I hereby effirm 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 wdrkers'
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 Policy No.
t" :nDMl'UNGLa NS. IZTWC'.53`u066-(*
(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, shalltforthwith comply with' those -provisions.
.Date: % IrC -k' Applicants
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 inspection purposes.
f' C1 . / � - e'llf
/Signature (Owner/Agent)!" r `- Date '
BUILDING PERMIT PERMIT#
DATE VALUATION�.idll.� LOT TRACT
C
JOB SITE
ADDRESS 52-165AWdV DAJH1a11,10
APN
773-212-01,5
OWNER
CONTRACTOR / DESIGNER / ENGINEER
?:?105.6v 1.11,1111 Ri.li;3iCa
840-15 CA13A:l N RD. INDIO. Cts 92201
LA QUINTA CA 922:S3
P),t II&I. ll1JSI;R11' CA 92261
t'iE10)130479;3 t;KI-A ;WI
USE OF PERMIT
SEP -14C ikAYV4D%)N, SL -%1!R CONNU t (W. 410D Pity?JIx A 49488 2U) t t
i {3Mr1CT AIk1G1JW 1,5 0,00 .C. a
A
'ESTbivUi%. 1CON`a or CONN 'Rull.710N
Ji
j,ox.,i
.
�pxq yin may. fp f.
Ri.i P MING FELE SEWER 1014M)"119-900 $30.00)
RUR 'in r -AL Il 'I'L11N l::i f [:C9
91100
LESS PR.I-Pt1Ii3l' ES
$0,00
TOTAL PC3ij1 I T FMA DUC NOW
S30.00
RECEIPT
DATE
BY f {)
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
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
Final
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
Final
Utility Notice (Perm)
COMMENTS:
ECONO SEWER SERVICES .
P.O. BOX 192
PALM DESERT, CA 92261
r7r.m 'Aa1;.97a1 r7rm '195t.77an
J00 D WORK ORDER
1081'�
FAX (760) 347-4978
DATE OF ORDER
CUSTOMER'S ORDER NO.
PHONE
MEC
HELPER
STARTING DATE
NO STATEMENT WILL BE MAILED.
TAX
BILL TO
ORDER TAKEN BY
r
� Gti
TOTAL AMOUNT
ADDRESS
/ ^
❑ DAY WORK
_ D P�
❑ CONTRACT
❑ EXTRA
CITY
i
JOB NAME AND LO ATION
JOB PHONE
DESCRIPTION OF WORK PAYMENTTERMSNIT
11/2% PER MONTH CHARGE AFTER 30 DAYS.
�1`�G for above work: or be mailed after
Signature
completion
I hereby acknowledge the satisfactory completion of work
of the above described work.
TOTAL MATERIALS
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE.
NO STATEMENT WILL BE MAILED.
TAX
DATE COMPLETED I WOWOFIDERED BY
r'
TOTAL AMOUNT
$
E] Noonehome ffotal
amount due ❑Tot I billing to
�1`�G for above work: or be mailed after
Signature
completion
I hereby acknowledge the satisfactory completion of work
of the above described work.