0005-112 (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
45`7554 C16 C36 MC 07/31/2(
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:
(-) 1 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.
UNITED PACIFIC INS NWA2722750.00
(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
yod
kers' compensation laws of California, and agree that if I should become
ject.to the workers' compensation provisions of Section 3700 of the Labor
e, I shall forthwith comply with those provisions.
Date: 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.afforney'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
t rstruction, and hereby authorize representatives of this City to enter upon
_Ne above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date
5' J 0 '()'j BUILDING PERMIT
PERMIT#
DATE VALUATION LOT
COMB -11.2 TRACT'
$1150010
JOB SITE
APN
ADDRESS SI -401 AVMA RAM. EZ
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LA. QtWrA UKAL MATE
IyU.°E.'FRIUM . iluka o
75.023 CAL.UE Wr/O0
4571 Si;flai'13Y• D . ES O -C
LA, Q131]it rA CA 92253
PALM 80PRUMS CA
92264
(760)322.3173 MIX 2229
04
s
USE or, PERMIT
SEPTIC A.BANDONISEWER CONNECT Ltii3LY.
VALi3A'FION i'
11,500..00 LZ
on
Iii"TINtt 1 :D CIOST OF COMMAX-Mon
��°.�.�� 12��,� ��avd•►vua��x y.
PLUMBINO FEE 101-000-419.000 F30.00
,t-
SUB -TOTAL CONOYRUCTIOX AND MA14 CHECK
$,1 0.00
UMS PRE -AAM FIT s
50100
1101-FYgromMs DUE .NOW
VD -00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
AN
INSPECTION RECORD
OPERATION
DATE
I INSPECTOR
BUILDING
APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath • -
Drywall - Int. Lath
Final
�} BLOCKWALL APPROVALS
Set Backs
Footings
= Bond Beam
Final
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
5
Gas Pioina
I Final
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)
OPERATION DATE INSPECTOR
.MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans 8 Controls
Condensate Lines
Steel
Electric Bond
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Final
COMMENTS:
POOLS - SPAS
'- e,..
- - ^,r-';ti!•:^.�•`.---tf�.�l r�{^'ST".°'i:'h-a"`�".'"7a
COACHELLA VALLEY WATER DISTRICT -1, . per. \ ` '
CASH RECEIPT DETAIL
Received From: ljl jt—_yent rnpor2fiA711 �1• I)EA I -h. G�3Lt(ATA %1_,'�P•�fa Date' r� '
D, Box
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Address: T-. Y
IA � ,. ��5
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7- -�
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Account No. ?4�" , i
+ Lot(s) iLV • Tract
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Service Address _4!5 1 t%1
' fa �{t• i+ bo : 4Z- . `i _. G.A. Code
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-i,
❑ Meter(s)
$
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❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
_
bMeter Surcharge
anitation Capacity Charge .o E,F2,'q.
);
❑ Temporary Construction Meter
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r ❑"Tu 1,,Charge n on
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❑ ._Uncollected Account -'Name
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F ❑ Inspection Fee - Tract -
'
Fee -
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❑ Plan Check Fees Water / Sewer -
-
Tract
❑ Bo:1d Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
Remarks: 7x:<a ._ k'r_ 00 €
pcto5y to:
F ash
Check
Money f
Order VWD-438(11/89)
TOTAL $ t
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Water Service
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