0105-199 (PLBG)LICENSED CONTRACTOR DECLARATION
I hefty 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
Pfofessionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penr:'ty 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
"- w...
'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' compensation insurance carrier & policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( 2.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 -6f Section 3700 of the Labor
Code, I shall forthwith comply with those.provisions.
'
Date: Applicant d. •:"^
,Wain ng: 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
the above-mentioned property for inspection purpose s.•_
Signatuxp (.Owner/Agent) . - `' .-----•-•••Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT }�,Q; TRACT
JOB SITE
APN
ADDRESS
y er f�eeyy�yy�1q��� �gg``pp, yy �pyp y
51-+ �tt9 Etk. bh.'ti9VIDA A'{A�.�3Mb' d65?:'F.i
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MJ0L,1?O',T1`:.A13�t.'�RLA
B=)ER
51 BGG A>fk?S!DA RAM
2u:18gm C.P. +92253
} C314
USE OF PERMIT
4 f. CON14E T.S"TIC° AHANOCINNI.04T
V•A%.I3.ATION 400.0911's
EXITzrd3.ATM COST M CONSTRUM@.i ON
40DAY6
PU1MBM0 YTK -- MWER 101-000-419-000
SUB-'!"dZTA.3:.. COMM Ji:7f:iON AND PLAN CTE.OK
$.30.00
LESS IYRTI-1;A:0 FM
$0.00
TOTALPIRMOTMELPS DUE NOW
I
-RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs i
Underground Ducts
Forms & Footings +
Ducts
Slab Grade t
Return Air
Steel i
Combustion Air
Roof Deck I • '
Exhaust Fans
O.K:to Wrap l
F.A.U.
Framing I
Compressor
Insulation !
Vents
Fireplace P.L. J
Grills
Fireplace T.O. I
Fans & Controls
Party Wall Insulation J
Condensate Lines
Party Wall Firewall J
Exterior Lath ]
Drywall - Int. Lath J
_
I
i
Final
Final I
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs J
Electric Bond
Footings ]
Main Drain
Bond Beam }
Approval to Cover
]
Equipment Location
I
Underground Electric
1
Underground Plbg. Test
Final }
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines ]
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out J
Equipment Enclosure
Shower Pans )
O.K. for Finish Plaster
Sewer Lateral }
Pool Cover
Sewer Connection ;
Encapsulation
Gas Piping
Gas Test J
Appliances
I
Final
I
COMMENTS:
.� • 07
«
Final I
Utility Notice (Gas) ]
ELECTRICAL APPROVALS
Temp. Power Pole I
Underground Conduit J
Rough Wiring
Low Voltage Wiring }
Fixtures
Main Service 1
Sub Panels ;
Exterior Recept5les
G.F.I. - I I
Smoke Detectors.. i
Temp. Use of Payrer I
1
i
Final. I
Utility Notice (Perm) )
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COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: /�� l .i°a Date` 15 "
Address: Y V• / %L `��%r �i G CL`�.f.C- �� �� v'
Account No. �'� /� f Lot(s))Tract
Service Address f " -� �� /7.f �7 G. err//' G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
W,
❑_ House Lateral(s)'
❑ DetectorCheck(s)
❑ Meter Surcharge u
' Sanitation Capacity Charge"'`
x.
a�
Cl W.S.B.F.C.
❑ Temporary Construction Meter s
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
;;; ` ❑ Plan Check Fees Water 1 Sewer - ' i'r
.. Tract -
";:,' ❑ Bond Payment.- A.D. - Bond
Assmt.
'❑ Customer Deposit
,�. ❑ Other
TOTAL $ /
>.. Remarks:
Q'Copy to: '.
Cash kc } Water Service
Y. Check
y Money r�i ,• ^ { Cashier
#�^r
Order .i r��i { a ..i �. ♦y� t rµ `ir 9 T''1. CVWD 438(11189),,,, y
�nt3 ,_.,u_.��....., F.•. >. ..I.�r. o...r... •1rc--1. n...M it uy.G`�, -.. S,.A�,; ,..y ..sr: ..�•.S..L9>a' a:, .,.., .E -.:ti. .1 ... it t!.. ir_..,L�'R .ia, .kti. `%.,._ t . l;.. A: ..._,-��_ 89)