9901-066 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
.I hapter 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
2429i0o
r
Date r r j Signature of Contractor f y
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
Se;Non'.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.
(301.,JM 13AM15 INS. NNVC 480066--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 shall forthwith comply with -those provisions.
Date: i ._ `orf Applicant •, -� �'
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 PERMIT#
99111 ilhf►
DATE((,,,� VALUATION fi�t��. LOT TRACT
00
,' �-(A
J06 SITE
APN
ADDRESS i3_5is A ENIDA tC�/Si1R0.
774-1JU13
OWNER
CONTRACTOR/DESIGNER/ENGINEER
In<'t: r''_AA1
l:virt�+Y;
4!r11��r�1 rC� c11
31555 AVl:,NIDA RLI -WO
W15 CAiBelZON RE). W010, CA 92201
LAC UINI'A CA 9221 KA
PALM UESEK17 CA
92261
!'7tit)1 iA15-27�;i CML#
347
USE OF PERMIT
KAXIBINIQ
SEPTIC iWANi?ON. SJEWWR C:ONWCT PROJECT #98-20)
\y�
LST11%1AT.E1) Ct�4,130ACO TSTRU(*- fa(IN
1,560.00
PERMIT $NE J66MR
M, __ 19H1WR 1014WA19-illi{? S30.00
Cf,A) f'f,)TAL d;'i?'Aj,CM� f0`f0N ANfPIMUfHFCK
�$�0fi
LESS PRE-TAID tES
.�0ot)
'-t3TAI., k'E"IT F"ENS 01)KNOW
.Sf►.flt1
IM0
RECEIPT
DATE
BY �
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
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
COMMENTS:
Final
Utility Notice (Gasp —
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wirirg
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Pohw
Final
Utility Notice (Perm)
ECONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
/7/•A\ AI/AAAA /1/•A\ AAA 11/•A
J08 WORK ORDEG°3'`
0901
/OVJ 3940-4/73 k/0V) 3L8 -//0V
DATE OF ORDER ;+
FAX (760) 347.4978
3 _ �
CUSTOMER'S ORDER NO.
PHONE
M ANIC
HELPER
STARTING DATE
BILL TO
❑ No one home ❑
Total amount due 061`6i1lA to
ORDER TAKEN BY
ADDRESS
�� ... �� d
O ��'
❑ DAY WORK
❑ CONTRACT
CITY
❑ EXTRA
�\
JOB NAME AND LOCATION
JOB PHONE
DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
144% PER MONTH CHARGEAFTER30 DAYS
6 A
Signature
for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
be"iiiaifof W7
ed after. 'yt..
completion a ,= �.-
s,. ��'� •".'til
TOTAL MATERIALS
TOTAL LABOR
PLLASE PAY FROM THIS INVOICE
DATE COMPLET R D BY
✓✓�J
TAX
TOTAL AMOUNT
'
;i t
$ .,d%,
❑ No one home ❑
Total amount due 061`6i1lA to
Signature
for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
be"iiiaifof W7
ed after. 'yt..
completion a ,= �.-
s,. ��'� •".'til