9711-063 (PLBG)LICENSED CONTRACTOR DECLARATION
•I hereby affirm under penalty of perjury that l 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
26. 2.1 C42, , 25,�?9
D to I�/Signature of Contractor ,A
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,, br 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 ofAhe property, am exclusively contracting with licensed
contractors to construct• the project (Seca 7044, Business & Professionals
Code). .
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
rlhhefeby 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.
STATR FUND 04cS9,0005268
(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,
1 --shall not employ any person in any manner so as to become subject to the
..orkers' 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: e'Ukavl Applicant
v
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 at 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
v.�
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 i"s'suedas 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, andkState laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propertjifo inspection purposes.
r Y C
Signature (Owner/Agent) y'! _ l 'y ' a�— Date!�
BUILDING PERMIT PERMIT# °°"yryTRpp°x�`
DATE VALUATION LOT 971_-1- 0 TRACT R-2- 7 ,
�i,5S0.00 �Vi 66. ��
JOB SITE APN
ADDRESS j j
5a-3I10.AVI�,N DA RAMIREZ 773.083-li1i�
OWNER CONTRACTOR / DESIGNER / ENGINEER
JEAN CHAVEZ A-1 CESSPOOL SERVICE, INC
ZI300 AVENIDA PU MIRE7 16819 Lri"I`LE MOR.ONGO RO.
LA CQUINTA CA 92253 DESERT HOT SPRING: CA 92240
(619)329-6875 C9L# -330+
USE OF PERMIT
SEPTIC AI3AMD0N, SEWER CCit i TECT.
VALEIM Wirt 4650.00 LS
ES`,CIMA ED COSI' OF CONSTRUCTION -1,650.410
PERM f FEE SUMMARY
PLUMBING FIX- -- SEWER 101-06;0-419-000 $30.ir0
d' 7I'AL CONSTRlfMON AND PLAN CHEClti. 30.IJU
LESS PKE-MAID FEES $0.00
NOV 20' 1997
TOTAL PERMIT FEES D.UE NOW $30.00
C"OFLAar� .
RECEIPT DATE BY' ATE FINALED INSPECTOR
t �'
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 PROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
d"
"�a'.'.'.v-n�¢:^7_'� �'. ;}'rT't?...,-... u-• '4. r. '.i, o,. "n:?it.'+.-: -.-'-�>ry-c•.• � .>��...yr� .... -- �... ..... a-
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: �? / F U� /'� " �� Date
Address:
p
Account No.L��ot(s) = Tract
[ Service Address ! G1 �1 t Lt Rav G Q + c n e r A. t
k ❑ Meter(s)
�. ❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
{ ❑ Detector Check(s)
❑ MMeterSurcharge
E Sanitation Capacity Charge
i
IF ❑ W.S.B.F.C.
I
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
C❑ Bond Payment - A.D. - Bond
i
Assmt.
I
❑ Customer Deposit
❑ Other
Remarks:
❑Copy to: C
Cash �=
Check v
Money
Order
TOTAL
Water Service
Cashier
t CMD -438111188)