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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
r 746139 C-12 MC f V281/2(
Date t� �" Signature of Contractor `i.e Y `�ti�" 7, Y
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 8r., 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.
PR have and will maintain workers' compensation insurance, as required by
,Sdctibn 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 2,7AT7±FUND Policy No. )S` IA,I_02
(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
Code, I shall forthwith comply with those provisions.r"j�+"
Date:��" �) v' Applicant ^,'r�s,,Rr.-�t!'� "" r' ",+_• :r .
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code,''interest and attorney's fees.
IMPORTANT Application is hereby made to the`Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
i
1. Each person upon whose behalf this application -is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enterE,uppra,w4
the above-mentioned property fdrr inspection purposes.
Signature (Owner/Agent) ` �"'""��i' Date a^ 0-16 ?1-
BUILDING PERMIT PERMIT#
0
DATE VALUATION Q LOTTRACT
JOB SITE��•��
ADDRESS .52442 At�.�.."v.�/A RKPIMUDA$
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
74-041 111HY 111
8403 r CARMU INId.). 1W510, C.A.922-177
PALM ;07MEMP C. A 92260
Pr.9:I,..M DESEW1 CA 92261
(766)346.2791 CRU f 342
USE OF PERMIT
si r 1711-AILAN"O:.NEMENTtsEWR HtIraKUP—
V:&•l AT7014 IS
NUM!l., XID MST (YF COMti UMON
2,5,00"coi
X11 SEWER 10) -ra€ 0.419-000
s,;FJ n
CITY OF LA QUINTA
FINANCEDEPT _ _m
l: -TOTM' ,Z'C1t 1 2iJ 1 t'�.i ►i i1 gal.►^ "rf r�" k
7 '3it,pi3
7'O'1' i.1�'1��R! Wi':!z'�'i� IDUE.I�I'OW
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REEt^hrr� ..,
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DATEy� / /
1,i'! jti
BY •^
E
DTE FINAL 3 ?�
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
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection c o j�
Encapsulation
Gas Piping
Gas Test
Appliances
Final:
Final
Utility Notice (Gas)
ELECTRICAL PPROVALS
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:
COACHELLA VALLEY17JATER OI TPt1CT , '
CASH RECHIP _,ETAIL Q L'
❑ WS.B,F,C,
❑ Temporary uonstruanon mew
❑ Turn on Charge
EQ Unoollsotad Account - Nam
❑. tnspectlon Fee —Tract
Cash
Thck
Morley
Order
Water Service
Cashier r
CVWD-438'
Signature
U No one home ❑ Total amount due ❑ Total billing to
for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work
TOTAL PUMP
EC SEWER SERVICE, Ill.
dba ECONO SEWER SERVICES
DISPOSAL FEE
P.O. BOX 192 e PALM DESERT, CA 92261
(760) 346-2793 (760) 328-7760
TOTAL LABOR
FAX (760) 347-4978
DAie.
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
SERVICE CODE
PHONE
TECHNICIAN
HELPER
STARTI,
BILL TO _
TYPE OF WORK
❑ CLEAN DRAINS
❑ CIT
K
ADDRESS) �• ^
v r l AVr �L�'2L(/((�(�%�t
❑AP
�AS
CITY
L Q� /�%�
SEEPAGE PIT
JOB NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 11/2% PER MONTH CHARGE AFTER 30 DAYS.
DESCRIPTION OF WORK:
CONDITIO F T BEFORE SERVICE
_ANK
Good ash & Garbage
_ Excessive soap
_ Fair _ Overflowing
_ Sand
' o, Poor _ _ Blockage
_ Repairs Needed '
_ Very"Poor _ Odor
Roots _ More frequent service needed
S� �C ,q,Q��bc�rE'7Y
17A CK FiLL s
dtozc
�\4 V
Signature
U No one home ❑ Total amount due ❑ Total billing to
for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work
TOTAL PUMP
DISPOSAL FEE
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
DATE COMPLETED
WORK ORDERED BY
TOTAL AMOUNT
IsIA
Signature
U No one home ❑ Total amount due ❑ Total billing to
for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work