0106-282 (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 # 5 Lic. Class Exp. Date
7
S. Crib '.?11/2(
!� r ' C -
Date ! Signature of Contracto �'.f
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 �j•�� Policy No.
(This section need not be completed if the permit valuation is i' r $\1100.00 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 stjall forthwith comply with-th6se provision"
Date: %'f -Applicant�`:'Jr-�-% c �^+." a-•� — '
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.
r
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.
r
Signature (Owner/Agent) Date ^Iv"
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01&S— TRACT
JOB SITE
APN
ADDRESS
¢D ,1Yt.
OWNER
CONTRACTOR/DESIGNER/ENGINEER
MAR. M& PAM9
R. y S CIDNSTRUC110M DR" MERVI(ITI.
'53-6$5 AV,U1,".;'il'JARC I-10
$2154'3'!U-19MLAVE
to QtrjD rA CA 92253
:C1 D10 CA 922:31
(760)342.917 ► Msr 1.81.9
USE OF PERMIT
SEVIER HO -OK -Up
I DTIC Ai%AAIX' OHE>WNT
VALU T1014 U11
MAT :) COS';fi" Off' C1�N:;5"�'R�U'Q$'1'I�+0
a�e 00
�.�T �:�y.'�S"4.
gy ^��t�. ��'7�+. 'C5'�� RM
b1.d :.iA'� .k` dile.'' R4.Y:►�dNLA�345. M
}' "UMB; IG M, 3X23• -W0,4.19.000 S;3g�Q4
s
t
W
D �
LJUN 2001
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CITY OF LA QUINTA
FINANCE DEPT
MB -TOTAL CO� WR UM011 A9D REAR CMM
$30.00
...IKYJ .rM L"'1MMU IPM .E3•i7bt6 NOW
MOO
RECEIPT
DAT
��' ���
BY
DATE FINALED
IPECTOR
NS
INSPECTION RECORD
1
OPERATION
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
t
ka T
BUILDING APPROVALS MECHANICAL APPROVALS
fr
Bond Beam
Set Backs { Underground Ducts
Approval to Cover
Forms & Footings II. Ducts
13
Slab Grade 1; Return Air
Steel 11 Combustion Air
Underground Electric
Roof Deck 11 Exhaust Fans
14
O.K. to Wrap 14,. F.A.U.
Final
Framing • • 11 'Compressor
Gas Piping
Insulation ]u Vents
Gas T
Electric sFinal
Fireplace P.L. it Grills
11
Fireplace T.O. 11 Fans & Controls
Water Piping
Party Wall Insulatior. Condensate Lines
Plumbing Final
Party Wall Firewall 11
{5
Exterior Lath ]I
Shower Pans
Drywall - Int. Lath 1 �
O.K. for Finish Plaster
!1
]3
Pool Cover
Sewer Connection
1 Final
i
Finals POOLS - SPAS
BLIOCKWALL APPROVALS
I4. Final
IR
COMMENTS:
Final j} r
' ELEI
Temp. Power Pole
Underground Conduit't
j Rough Wiring �]
Low Voltage Wiring {I
Fixtures I+;
I Main Service {1
Sub Panels H
Exterior Receptacles Ji
G.F.I. l3
Smoke Detectors !
Temp. Use of Power IE
is
it
Final I I
Utility Notice (Perm) 11
APPROVALS
I
-;
1
Steel
Set Backs
Electric Bond
Footings
t
Main Drain
Bond Beam
1F
Approval to Cover
13
Equipment Location
I
Underground Electric
14
Underground'Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas T
Electric sFinal
Waste Lines
11
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
{5
Equipment Enclosure
Shower Pans
li
O.K. for Finish Plaster
Sewer Lateral
]3
Pool Cover
Sewer Connection
IY 1
1 Fncaosulation
I4. Final
IR
COMMENTS:
Final j} r
' ELEI
Temp. Power Pole
Underground Conduit't
j Rough Wiring �]
Low Voltage Wiring {I
Fixtures I+;
I Main Service {1
Sub Panels H
Exterior Receptacles Ji
G.F.I. l3
Smoke Detectors !
Temp. Use of Power IE
is
it
Final I I
Utility Notice (Perm) 11
APPROVALS
I
-;
v`1
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: / ►' 1/� 2AAC. I A. L, PAQ KS
Address: O -f1 6 L? N rev
--r_ / . d 17
- Account No. C Lot(s)
-un
R L
Service Address '?+�
_ 0 o
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
Surcharge
�r
Sanitation Capacity Charge'!
5 S
❑ W.S.B.F.C.
❑ Temporary Construction Meter
O Turn on Charge
❑ Uncollected Account -,Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract - r
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
WTO AD fPAO
191' Tract S
G.A. Code
$'
I �5
TOTAL $ / / ZS•
Remarks: LU! L L /6A)
opy, to:
Cash Water Service
Check 2 ��
Money
Cashier
Order CVWD-438 (11 /89)
(e7