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9901-060 (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 746159 1.42 `' V29/lit) ,/Date ! ` Y 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 y 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 Policy No. COLMINVEAGL [NIS. I XC`43066-00 (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 shalhforthwith comply with those.provi'sions. Date: f ' �% ApPlicantif�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 inspection purposes. Signature (Owner/Agent) Date BUILDING PERMIT PERMITy`,t�� a►��i DATE VALUATION' LOT TRACT 1 C s 19 52.200.00 JOB SITE APN ADDRESS 5�85 AVE!`iID A. RUR10y% 7.�1-2 t✓ -014' OWNER CONTRACTOR / DESIGNER / ENGINEER - t�ni. JINNI N, GERT r•ATnt Ef,U'`dr) vc;iA rj, r.L,nAf1CI-.. � � ,.. a �'i :.1,-.aaG: �,,.c y.f 1.. .. � �.. i�...r t.. � .!•,�� s 32495 A VENH)A kM0 9411.35 CABAZON RD. N DIG, CA 9220.] LA QyAN`S'A CA. 92253 PAIM DESERT CA 92261 (760)340:-2791 C:'BIN 442 USE OF PERMIT K.tlAlNNG SGYTIC ABANDON, &SWE t CONNECT (LO -MOD PROXCT 498-220) C©i%r -, RAC7 AMOLMT h 200.00 LS A w9,lAA.lYEC9&•tlr.tl.� �.l.�S V'AF' CONSTk�.4.I'A.•TI'i..>i^�r '6 yo+ ��I.e �9 PLUMBI[NO FEE -- sFwIrA 101-000-419-000 S30XIO ti0-iB I'3 AI, 0_)N8'F1K _)(' !0N AND :f3i AN ("W471K. LESS PRE. -PAID FEES $0,00 g+'ECS 01.1PI"NOW b>111.6d06 RECEIPT DATE BY DATE FINALED INSPECTOR L' r 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 Qr%n1 -qdF-77Q 4 (74;n) 39A -776n JOB WORK ORDER x10901 FAX (760) 347-4978 DATE OF ORDER w L O CUSTOMER'S ORDER NO. PHONE MEC IC HELPER 5TAFrrING DATE BILL TO7'00/ ORDER TAKEN BY 05 NO STATEMENT WILL BE MAILED. ADD NES ❑ DAY WORK ORDERED BY ❑ CONTRACT CITY C 1� ❑ EXTRA JOB NAME AND LOCATION JOB PHONE DESCRIPTION OF WORK YATIVItNI. I[KIVIJ IYCI 1V VNTJ rnwivi wmm yr aanvrvc 11/z% PER MONTH CHARGE AFTER 30 DAYS. C Signature for above work: or be mailed after completion I hereby acknowledge the satisfactory completion of work of the above described work. {TOTAL MATERIALS TOTALLABOR PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TAX DATE COMPLETEDWORK ORDERED BY TOTAL AMOUNT $ ❑ No one home ❑ Total amount due ❑ Total billing to Signature for above work: or be mailed after completion I hereby acknowledge the satisfactory completion of work of the above described work.