9603-110 (PLBG)LICENSED 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
cl (Jttt�I C-42 1 HY31.97
Date Signature of Contractor
OWNER -BUILDER DECLAqexer�pp
N
I hereby affirm under penalty of perjury that I am 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).
O 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%sue8:, M,,y,"W.orkers' compensation insurance car-rrie-r,;.&.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„ proi1bris of Section 3700 of the Labor
Code, I s II forthwith comply wit' thh p. isions!
Date: Applicant
Warning. Failure to secure WorkerstCompnsation coverage is unlawful and
shall subject an employer to criminal penaltie 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
DATE 3/26196 VALUATION sq
oo LOT
PERMIT # CONTROL #
9M)3-1.:10 3013
TRACT
JOB SITE
ADDRESS 54720 ADA RUBIO APN
'V":,1. :774.27x-011
OWNER CONTRACTOR / DESIGNER / ENGINEER
f
GREIAT Wi��.'"'i`isRN BNNte. l:CONQ S cMT,13. SE RVIC
54720 AVE7rli'T7t�. RU.i3iiJ K.is'� }+:'!i t�~Lr,�iN kl).
LA QUIN -CA CA 92 25'3 PALM DESE- a'T CS 92261.
(619)346-7793 t BL#k 342.
USE OF PERMIT
SF`VUCTL OfliJ'sdfs'�''�'1C?N
ESTIMATED (XIS'i O CONSTRUCTION
PERN1111.1' MI, NVAIMAitY
11.1 vtt!ll'NO WICK 101 -NO -4119-000 $3t).fii1
906.00
SUB -10 AL CONS'' AIDC ION. AND PIAN (211.ECK. $30.00
LESS PRE -MID R S $0.00
T43°S`M., 8'ERN111.6+EWS-ilyUE OW 43t1.a11i
MAR 2 6 1996
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
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:
.•• .. '.tom -a� �
4 COACHELLA VALLEY WATER DISTRICT+- CO
r - SH RECEIPT DETAIL
CA +
Received From: v' Date
i•�l (_ -Lr :� /;.•' `> � �.
• _
1/3
Address: •1 // _/,;
( _ L ft7 �.., " �?
o. i
Account N =,- . Tract
( Serviceress!;� 1- -' <_ 1 G.A. Code .1
❑ . Meter _ $ ,
i
❑ Service(s)
❑ -Backflow(s) `
❑. House Lateral(s) "
❑ DetectorCheck(s) {1
- ❑ Meter Surcharge
O anitation Capacity Charge
❑-W.S_B.F.C.
-❑ Temporary Construction Meter'
❑ Turn on Charge
❑' Uncollected Account - Name ,
❑ Inspection Fee - Tract
'Y Fee -
❑ Plan Check Fees Water / Sewer -
Tract - I
❑ Bond Payment A.D. - Bond'
Assmt.
❑ Customer Deposit
D Other _
TOTAL $ > (i
Remarks: w
❑ Copy to: '
Cash Water Service_— i
Check
y ff) J-`✓ ,, - ~�.. /�
r Mone i ` 1. : Cashier
Order t ;; CVWD-438(11189)
gCONO SEWER SERVICES
P.O: Box 192
PALM DESERT. CALIFORNIA 92261
AM �oaao�o�a
46978
PHONE 328-7760 346-2793
TOTAL MATERIALS
CUSTOMER'S ORDER NO.
PHONE
ME IC
H ER
STARTING DATE
BILL TO
(,,
1
ORDER TAKEN BY
ADDRESS
/
TOTALAMOUNT
Is
DAY WORK
CONTRACT
EXTRA
CITY
'AND
JOB NAMELOCATION
JOB PHONE `
PAYMENT TERMS NET 30 DAYS FROM DATE OF SERVICE
1%% PER MONTH CHARGE AFTER 30 DAYS
'
TOTAL MATERIALS
TOTALLABOR
-1 EASE PAV FROM THIS INWO'eE
NO STATEMENT WILL BE MAILED
TAX
D CO�PD
WORK ORDERED BY ,
TOTALAMOUNT
Is
! 1 ❑ No one home Ej Total amount due ❑ Total billing to
Signature for above work: or be mailed after
completion
PRODIM:7 258.2ees. Inc I hereby acknowledge the satisfactory completion of work
Groton Mam 01471.. of the above described work 0