9903-268 (PLBG)LICENSED CONTRACTOR DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of
Cbgbtar 9 (commencing with Section 7000) of Division 3 of the.Business and
Professionals Code, and my License is in full force and effect.
License # Lia Class -Exp. Date
r` "I.0159 C42 C" 2I29it0
ate'?rf-�C�Signature of Contractor, t'��'r ' •-----
r' � r•
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' compensation insurance carrier & policy no. are:
Carrier GOLDEN EAGLE .Policy No.
(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
C/de I shall forthwith comply with-tho es provisions.
mate:"' Cln Applicant
t�
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
the above-mentioned property for inspection purposes. /
,Signature (Owner/Agent) ti `�" Date+r'
BUILDING PERMIT PERMIT#
DATEJ VALUATION $1,,-%00J)0 LOT TRACT
w
JOB
ADDRESS 52-105 i�Or��.�.lalIDA Rk�I�`.�I�-�! ,
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
DAVD C"h::rBURN
PCOM) SMVER SERVICE
3673 GREEN ACRES DRIVE
84035 QA.BA7X.)N RIS. ' 010,
CA 92201.
cA.ksoN ct'! y'
PALM DESERT CA
92261
C7nt)4346-2743 Ci3[..,fi
.
342
USE OF PERMIT
ML.lJ�131Nr.
-
SEP iC ADAAdi10N - SEWER ER HOOi- UP
vALUATif: N LS
&TrIMATED COSIr OF e:.'ONS':RIAC-1-10
1" ,9.0:)
primmrr 81JRomm.,
✓LUMBIbW flM -- SE WPA 101-000.419-W) t1i �jtj
`9.,rx)-K)TA),CONSM (,ICTI N'� AT10 Pl..AN f';IaE(:.'k.
$30 illi
LE". 'PRE-11"MD FEES
$0.00
TOTAL @'FRMIT IN 1?,KSi DUE, NOW
$.30.00
lJ.
RECENT,
DATE,
BYI�
DATE FINALED
INSPECTOR
r t%
p
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
f 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
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 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)
COMMENTS:
ECONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
f -yr^'. -1% r I -Fe^% N^n
J08 WORK ORDER
09212
kluvj kivVy .2dao ./I
DATE OF ORDER
FAX (760) 347-4978
CUSTOMER'S ORDER NO.
PHONE
MEC�
HELPER
5 HTINU DATE
BILL TO
ORDER TAKEN BY
ADDRESS
OMPLETED ED BY
WOPW RDER
;4�F iA E
TOTAL AMOUNT
DAY WORK
..o�Or ;�5 No one hom7 .
&Ioio<.ojp _,00� e !KTot6l
amount due TotalSilling to
CONTRACT
CITY
'0000000o�
0�
EXTRA
JOB NAME AND Lft'CATION
JOBPHONE
DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
1.16% PER MONTH CHARGE AFTER '40 DAYS
Signature —fo"(above work: or be mailed after
completion
I hereby acknowledge the satisfactory completion of work
of the above described work. 0
TOTAL MATERIALS
TOTALLABOR
PI FASF PAY FRQM THIS INVOICE
III HE MAI[Fr)-
TAX
OMPLETED ED BY
WOPW RDER
;4�F iA E
TOTAL AMOUNT
$
..o�Or ;�5 No one hom7 .
&Ioio<.ojp _,00� e !KTot6l
amount due TotalSilling to
Signature —fo"(above work: or be mailed after
completion
I hereby acknowledge the satisfactory completion of work
of the above described work. 0