0206-043 (PLBG)LICENSED CONTRACTOR DECLARATION
.,.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
Profes"sionals Code, and my License is in full force and effect.
License #Liic. ClassExp. Date
482180 421 Ctry (ir7��1tit
f
C,-...
Date h� "r. a.2a. 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).
() lam 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.
(�c 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 STATE FUND Policy No. 0733401 -DI
(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:,, Applicant •7` i'•_' r 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, 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
fthe above-mentioned property -for inspection purposes.
1\Signature (Owner/Agent) s ! Ii / (' Date Z_
BUILDING PERMIT PERMIT# .
i� r
AT
VALUATION LOT TRACTJOB
SITE
ADDRESS « 0 •iTF�e e� }����ZY.H. Ye
APN
OWNER
CONTRACTOR /D.ESSIGNER EN1NEEER
YpY;ES. nnt.0,
"IT
9WMSy09DEROWiiAD COM
3.7'20A•.v"1" aA MOII"IF,Z(.31A
38703 V19fA DIONE,
LA QUO M. c:':A 92253
CA:MMWL L CITY CA 92234
(7(K)324-1911 CaLff 769
USE OF PE7R1p�MIIttT��y�
7
SF, 11C,AMN1-A)30;SfyWERH0,01(-UP
VALUAT1014 1-10,
r'i:tRi� miD con' +axe c..°c ngrRiya noN
PLu-mi3ri 4v Fix r,. +E) 101-000.419.000 $30.00
De
JUN 08 [itQ1
MIYOFIAQUIMTi4
�MCEDEhF ` ,w
t(1:iB 1-(Yrtl, COM1R:U 1 ON AM) PLM (MRQX,
slf3 bo
L}:e� 7 t''R)_?? .PAO PIMS
$0100 ,
RECEIPT
DATE
BY
D;E.FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
s
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
Fthal
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Wa a 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) ( 6 L
ELECTRICAL A PROVALS
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:
.- �,r! �,1� � COACHE41-A VA49Y WATeR pISTRICT winAN V MOM
Recelved Fro L. J J 1
Address:
Account No, Lot(
Service Address
❑ Meter(s)
O
Service(s)
❑ BsokflPw(s) _
Q House Laterat(s)
❑ DetectorCheok(s)
❑ Meter8urch*rpe
anitatlon Capacity Charge
❑ W.S.B.F.C.
Q Temporary Construction Meter
Q Turn on Charge
Q Uncollected Account - Warne
Inspection Foe - Trach
Fee -'
Q Plan Check Fele Water, / Sewer
Tract
❑ Bond Payment - A.D. f9ond
Assmt,
❑ Customer Deposit
Q Other.
Remarks:
Q.A. Code
TOTAL
S «K•- t ? 1
❑ Copy to:
Cash Water Service -
Check j� (�►�^- r
Money Cashier
Order �w. CVWD-439 (11189)
_ Jd
JOB INVOICE
CATHEDRAL 'CITY, CALIFORNIA 922;
17am Qan _ SAAR, .
i7"6_0_,)_32__1-7448
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE ORDERED
....
Gallons
ORDER TAKEN BY-
DATE PROMISED ❑ A.M.
❑ P.M.
BILL TO p�+�y.'
PHONE
ADDRESSHANIC
Dumping Fee per 1000 gal.
�[S
CITY -
J
`
HEL PM
JOB NAME AND LOCATION
DAY WORK
J r
DESCRIPTION OF WORK
❑ CONTRACT'
-
'
-Locating / Opening Fee (per hour)
0 EXTRA
®
U
DANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
L
Dumping Fee per 1000 gal.
�[S
Out of Area Fee '
-Locating / Opening Fee (per hour)
Size Syst m
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS..
18% PER YEAR WILL BE CHARGED ON -
PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
- LABOR AMOUNT
TOTAL
MATERIALS
MECHANICS Q
HELPERS Q
TOTAL
LABOR
"t I hereby acknowledge the satisfactory TOTAL LABOR '
ycompletion of the above described work:
J, 'T,tJRE
TAX
s=
DATE COMPLETED
TOTAL
1