9901-051 (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
7,161.5-9 tC,12 2129/00
/Date - &gnature of Contractor
j l
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' compensationinsurance carrier & policy no. are:
Carrier Policy No.
C;OLL)EN r,' GI.r INS.
r��,zv�C ���•-+�
(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: ftp 1�Applicant - a
Warning: Failure to secure Workers' Comp4nsation 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
the above-mentioned property forinspection purposes.
Signature (Owner/Agent) Date f
BUILDING PERMIT PERMIT#
9zil)�-Ur:3
DATE VALUATION LOT TRACT
JOB SITE'
ADDRESS .�' J.t ` 5 AVE,NI NIDA RAMI EZ
APN
773-082-421 '
OWN
CONTRACTOR / DESIGNER /�iENGINEER ,
r
AAER //��T �•. c p t R,(
N! 11. RC l-�,3 M.:.R-i...A, 1�0
C/ r
FCOi�r� i S117�v�1'R .S.ti: il.��iCE
5140.5 AVENIDA f2.61.N11€LCZ
4403.5 CABAZON R.D. 1ND1O, CA 92201
LA QUCNTA CA 91253
PALM DESERT ' CA 92261
(760)346-2743 (131.0 341
USE OF PERMIT..
PLUIMBNO
SEPTIC ASAMOR SEWER CONNECT (LO -MOD PtiOJ- -i' u98 -2)j
CONTRACT" a'uN1. ili+: a 1,W.00 l..a
I,s 0.a0
PERMIT �1�'✓E SU:WIARY
PLIAVffi G FI -X -- SEVER 101-000-419-000
53 IRVI'017A:I., C O NSTRI.I("'['iON AND VLAN C HFCK.
LESS PRE-.fi'U.D FEES
$0.00,
TOT AL PCR.iMIIT FF WN 0 U E N 43
530.40
1A
RECEIPT
DATE
BY ,; �
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali 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 PI . Test
Final I I
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 Wining
Low Voltage Wiring
Fndures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
ECONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
1 t % - -
JoB W(ORK (DRQER
1081-2.
klati) 314o-Z/Vj
klov) ae-0-110V
DA; 07 CORDER
FAX (760)
347-4978
-7
_ --" '?
1 4�<- �-- tl;p
CUSTOMER'S ORDER NO.
PHONE
MECHA
HELPER
STARTING DATE'
BILLTO
ORDER TAKEN BY
ADDRESS
< 7
DAY WORK
El CONTRACT
EXTRA
JOB NAME ANULOCATION
JOBPHONE
DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
1%96 PER MONTH GHARGE AFTER 30 DAYS-
TOTAL MATERIALS
TOTAL LABOR
TAX
DATE C07
TOTAL AMOUNT $
0 No one home X Total amount due E] Total billing to
\,for above work: or be mailed after
Signature letion
comp
I hereby acknowledge the satisfactory completion of work
of the above described work. 0