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0308-110 (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 M Lic. Class Exp. Date 482180 C21 C42 y ate l :_t ; Signature of Contractor 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. ( $Y. 1 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 COMBINED SPECIAL Policy No. 00S-00011613 (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 Q0de, I shall forthwith comply with those provisions. Vate: 4r. ' a t Applicant I t i��. - , •;* 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, indemnity & 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# 0308-2.86 DATE VALUATIONy f LOT. TRACT C' JOB SITE APN ADDRESS .5, ti.••31M AVF..MDA'RAURZEZ - t. OWNER CONTRACTOR/DESIGNER/EN (NEER t TARA I-iETWER Alv.1dI311mERCiRoum CC)1`1n. 51-385 AV IDA RA:MMEZ; 38703 V'ISTA.DRIVF?. ' ?.A QU.D4TA (,!A 92253 C.A71-IRDRAL. CM CA 92234 (760)324.1911 C73LO 769 USE OF PERMIT PI.,LT.MTMNO SPY:'PIC BAN DOBfM,rNT AL141) SEWER H00t.- JP VALUATION 2.090,00 LS NSTINWrED COST OF C( NgrRUC17014 PES FEE UUNW .RY P1.UiV1BIN10 FEE -• SL:WER 101.000-4? p-000 $30,00 � D e AUG o 8 2003 CR LA A 1OF 1 CE DEPT. SUB -TOTAL CvONUMUCC1ON AAd]" PIAN CiiWK $30.00 LF -213 PRE -PAM IKEES $01010 VYI AL PERI IT B1' IES IDUP.' XONV -go RECEIPT DATE BY QeL or FINALD INSPEC rr9.- %• © -5 �i -Z - d 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 8 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 - U Encapsulation Gas Piping Gas Test Appliances - 0 Final d COMMENTS: 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) w COACHELLA VALLEY WATER DISTRICT CASH ECEIPT DETAIL ""„ 97402 Received Fro do, v v 0 +` ' .3 " Datev Address: 1r Account No. , L tls) > Trac �� �� 1`1 Service Address G.A. Code ❑ Meter(s) ❑ Service(s) ❑ Backflow(s) ❑ House Lateral (s) M aa;,;:., . ❑ DetectorCheck(s) ❑ WleterSurcharge ❑Sanitation Capacity Charge ❑ . W.S.B.F.Ci?. ❑ ,Temoorary Construction Meter 'Uncollected:Account ❑ - Name :, •r�;v ❑ Inspectlon`Fee'- Tract = %i s .t TOTAL $ _,00 �i ,q — ❑ Plan Check Fees Water I Sewer - . Tract ❑ Bond Payment - A.D. --Bond,: ` Assmt. 4 N� . 1 y� ❑ Customer Deposit , Cashier ❑ Other ,ogll J�a ❑copy to "�'• t � �ti��� � �`�> H Check's money;y Order A %i s .t TOTAL $ _,00 �i ,q 'a �S Sim Water Servicetct 1 f , Cashier �A A s .t TOTAL $ _,00 �S Sim Water Servicetct 1 f , Cashier AN - 2502 Morongo Trail ,,q PUMPING SERVICE ;'1 Palm Springs, CA 92264 1 2249 (760) 327-8859 SOlLLDT�O SALESMAN TERMS SHIP/PEED TO DATE /''"— STREET, � r a.) STREET , y lP CITY STATE ZIP CITY STATE ZIP i` CUSTOMER ORDER SALESMAN TERMS F.O.B. DATE /''"— r a.) i` r PAYMENT: DUE UPON RECEIPT