9909-024 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ghapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my.License is in full force and effect.
License # Lid; Class Exp. Date
7461.9 G�#?C _... - .: 04'J29i20(
ate9-Y -�?9 Signature of Contractor;'
d
OWNER -BUILDER DECLAR TION
I hereby affirm under penalty of perjury that I. am exempt from the Contractor's
License Law for the following reason:
( .) 1, -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
ke,formance 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.
(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 shall forthwith comply with -those. provisions.
Date: �/: /.: (247 Applicant r. ,d
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.•purpoges.
Signature (Owner/Agent)r Date
BUILDING PERMIT
DATE o9foinggVALUATION q;2.0WLrg) LOT
PERMIT #
"09-0111
TRACT
JOB SITE
ADDRESS 52-575 A ENIDA f;EUBIO APN 71.242-k6
OWNER aaSS ,NIM'
!! CONTRACTOR / DESIGNER / ENGINEER
Ai.Iid3Vl,NI ..'N 4OM() S13''a.'t R S"Or,E
52575 A.'1+FR;iDA :1i:UB10 8403.5 Cliklx'LWN JU). air D10, CA 92201
1,A QtAN A CA 92253 17AI.Ad DESUMf CA 9226
(760)3A&2793 C131A 342
USE OF PERMIT
IJLI.iMUNG
SEPTIC ABAtdl.' OIIZa SEW CONNECT
%'�1'i,{)r'e1.10N
:x,.i1( -00lLS
c�i�rr SD,�l6'C )e�i..+4.rf91 d,d:�' R.�'LiL'Vi.B•tl.•0]RIA�.•.tl�Ati.AA'v
P , 1.x"1 FE K SUMMARY
RLUMB:1.NO FEE --- 9100i 'ti (OA -lift -419.4300 530.00
t' -
i
StYR-7111FA.1, (`OMIMLK:" 101 ,4M) PLAN C''"Va,
LESS R7i7ID FEES nn+,
fl,0
RECEIPT I DATE a [BY I DATE FINALED I 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 Band
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 2
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
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)
Water Service
Cashier_
NRIF
COACHELLA VALLEY WATER DISTRICT ='
r r ry
CASH RECEIPT DETAIL ✓ .. ,
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ReceivedFrom:' l
Address.".�jf"°)
No. ot�s1 '
. Tract
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•Account
Service -Address
*G A Code
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O Meter(s)
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❑ Meter Surcharge
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❑Inspection Fee Tract:
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❑ Plan Check Fees Water /.S �� y'* • �' r:
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TOTAL
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Water Service
Cashier_
SIJ AT E'q
��STRIG�
DIRECTORS
ESTABLISHED IN 1918 AS A PUBLIC AGENCY
,t0, 1 • ,f l'4y
19 pre
COACHELLA VALLEY WATER DIPAIST...,��n
POST OFFICE BOX 1058 • COACHELLA, CALIFORNIA 92236 • TELEPHONE (760) 398-2651 • FAX (760) 398-3711
JOHN W. McFADDEN, PRESIDENT
PETER NELSON, VICE PRESIDENT
TELLIS CODEKAS
RUSSELL KITAHARA
PATRICIA A. LARSON
September 15, 2003
Leo Vasquez
78-450 Highway 111
La Quinta, California 92253
Dear Mr. Vasquez:
OFFICERS
STEVEN B. ROBBINS,
.GENERAL MANAGER -CHIEF ENGINEER
JULIA FERNANDEZ, SECRETARY
DAN PARKS, ASST TO GENERAL MANAGER
REDWINE AND SHERRILL, ATTORNEYS
File: 1112.
Subject Y 52 "'575'°Averiid'a4Rubr o=
Account No. 606122,291.0.6
In response to your,inquiry,, all sewer requirements for the -above -referenced
property have been ;met.. It•wi11 be the -'homeowner's responsibility to
connect their pipeline to,the-sewer lateral.
If you have any questions please contact Rosie Anacleto, Customer Service
Representative, extension 2410.
Yours very truly,
Steve Robbins
General Manager -Chief Engineer
RIA:ra
bc: City of La Quinta
Post Office Box 1504
La Quinta, California 92253
TRUE CONSERVATION
USE WATER WISELY