9701-086 (PLBG)LICENSED CONTRACTOR DECLARATIOr4
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 f Exp. Date
�� Sf393! C-36 11913
/Date X 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.
( ) 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.
F–MMI)T'iON 01.4 j-41
(This section need not be completed if the permit valuation is for $100.00 or less).
X) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manger so as to become sub Act to the
workers' compensation laws of Californieand agrre�e thaj,if I s0hoy�ld become
fi_.•;._.. �� Oaf
subject tR the workers' compensation-ptovlswns o Se on 370" of the Labor
ode, I shall fo with comply with tho a proAio�. /(�%
/Date: 11 l j� Applicant—.,'-,�''
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 a,pd state that t e above information is
correct. I agree to comply with SII City, And State I wsrelating to the building
construction, and hereby Buth�ie re?resent iv of this City to enter upon
the,above-mentioned prop'er(y3'for. inis� actio p rp� es.
' nature (Owner/Agent) r� Date t�
f 1
I
PERMIT#
BUILDING PERMIT
CONTROL# '
1701.-086
4627
DATE W1197 VALUATION S,1 Jr Q0.f)J) LOT TRACT
JOB SITE
ADDRESS g,;Z-914)AK�'Y:el.�JDARAM0W4,�4,
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
".l'l-IC7MAS 3, UfF:IN BROKERS
scutr COMNIINITY
i?t�l Vt1Ti I'Nt:r i7lt, S` 'I .
PA i3C7.X 2196
PA;i:40E)l SFIRT CA. 92260
INU10 CA
�
92210
CRIN
1
2571 Lam_
USE OF PERMIT
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L' SS PRE -PAID FEES
a.
$0.00
&'%Y'i'c���'It'€dMIT�'tr:F;JN'I)UE`I�dt)4i''
S311,00
RECEIPT
DATE
BY r
DATE FINALED
INSPECTOR
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 j
- 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
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines Z
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral z
'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 Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
. COMMENTS:
F
95
COACHELLA VALLEY WATER DISTRICT e'
CASH -RECEIPT DETAIL Ng ' �94
S Received From:�s r '1•i ii% 4iZ • LJ�F J i �) Date•
Address:. g S� $i�EA GtJ/► 2 t 1 Gr I��IR 57'F s A� L �-- S �T fk !27- Z [�
Account No. tt:�fZ�, /� .� Lot(s) Trach F3 LK 59_
Service Address 9/0' AVIA111�A MoLr I G.A. Code
❑ Meter(s) ' $
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑. DetectorCheck(s)
❑ Meter Surcharge
. a
V,46�itation Capacity Charge An
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge'
❑ Uncollected Account - Name
❑ Inspection Fee - Tract
Fee -
i ❑ Plan Check, Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond ,-
Asamt.
❑ Customer Deposit
❑ Other
TOTALZS
Remarks: C! LASTIII j JK. �) I _gc k f?V?1-no pl AF7-C2 'iilam/
•lji106pyto: % SWILL- P ri-whTr:0 ae etNnA6� mlCj >p'T/7IAN 1 S
Cash z x�f bV. p WtiaterService
Check
Money Cashier
Order "•''. y' CVwID-438(11189) .