9811-132 (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
2730$8 C36 Ii%30/99
Date i .S� Signature of Contractor
� !// Ste' g
OWNER -BUILDER DECLARATION f
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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.
(e) 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):
( ) 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'Sectio, 3.700 of the Labor
Code, I sh II fo7rt with comply with those p�ro'.isions.
VDate: L�� 'Applicant
Warning: Failure to secure Workers' Compensation cove ar ge 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"k,
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) + %'✓--%a '� Date / ;- '
BUILDING PERMIT
PERMIT#
DATE VALUATION LOT
`' TRACT
11125/9
JOB SITE
APN
ADDRESS „53-580 AVJC�l ��. {AM,IIMZ
774-122-•004
OWNER
CONTRACTOR/DESIGNER/ENGINEER
R013I R!P .EN0PL
VALI 133-Y IPLUMBING
33580 AVFNg1)A JUWIREZ
46 78 C UNTON
LA QUINTA CA 92253
INDIO
CA 92201
(760347-3649
(:Til N 101
USE OF PERMIT
PI,'iJ1Vi.t WIG a
3.UTTI ABANDON, .SLWIlk CONNECT
VALUAT1014
2, ftf0.fft3 1.3
i_n 1UNIAp. FUIL.) C'��,�1T
0.1.7, 'MSTR CTIGN
2.SiQ3#D.t30
.-Lfr1.MBR,1t,}: "rl -- SEWER 101--1100-419-000
t14�
IN
0
M ' , KYFAl , C �N '7'tt f: ;�t�.�} AN1? M .r1`N Cfl ff:fC
no
b.LESS
y. D FEES
DUE NOW'
S30.00
J
[RECEIPT ��lj n
w
DATE
BY/
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
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
Heater Final r
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection /
Encapsulation
Gas Piping
Gas Test
Ap liances
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:
11/25/88 08:35 FAX 7603478771 MSM & ASSOCIATES
J,
• tt
TOTAL FINANCIAL SERVICES, INC.
73925 HlghvMy 111, SUlto H Telephon, 760-773.9535
Palm Desert. CA 92260 Fox 760-7732808
• November 24, 1998
To: Coachella Valley Water District
. s
Robert Engle and Nancy Chin have been pre -approved for the purchasc of 53580
Avenida Ramirez, La Quinta. Escrow has been opened with Palm Desert Escrow with
Judi Rogers #98-3030JR. The fee for Coachella Valley Water District can be paid with
the proceeds from this transaction through escrow.
Q02
14r G✓ pays®�,�T'1on�l eisorlahl 4CIC ��111ee 46 ,
SCAJO"�_ Ar &Cr- Ae Ar 613VO Avo;ro,
wATe
1 ��dTfi1C .
COACHELLA VALLEY WATER DISTRICT
THOMAG J. O'RREZY. C.P.A.
P-0- BOX 10M, CMCKEU A. rAIJF. 92299
TMAPMMOMG, 040) Nil-==
a' "
(760) 36U- /4425
CUSTOMER'S ORDER NO.
DATE ORDERED
(760) 321-7448
1 O -
'
ORDER TAKEN BY
DTE PROMISED 0 A.M.
P11
umping Fee per 1000 gal. (�
0 P.M.
BILL TO n
PHONE
DDa
MECHANIC
ADDRESS
ER
CITY
JOB NAME AND L CATOION Key Y. `
��"
% � � �
(^
Zj-dAY WORK
�. •
.0 CONTRACT .
DESCRIPTION OF WORK
Locating / Opening Fee (per hour)
,0 EXTRA
cA. Q. r
Size System:
QUANT.
- DESCRIPTIO F MATERIAL USED
PRICE
AMOUNT
Gallons
P11
umping Fee per 1000 gal. (�
W�
Jcll�-
DDa
Dumping Fee per 1000 gal.
. `
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR AMOUNT
TOTAL
MATERIALS
MECHANICS Q
TOTAL
LABOR
HELPERS Q
I hereby acknowledge the satisfactory
completion of the above described work:
TOTAL LABOR
'TAX
SIGNAT
�% , /D ,
DATE COMPLETED��
(( 3 Gi 5 b
TOTAL
1
i�S