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i- 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
74415,9 C42 FAV_
Dater �°'f Signature of Contractor C
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. 157M-21 -01
(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 it I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those_ provisions.
ate: � _ 1 `"' ear Applicant`:
Warning: Failure to secure Worl&s' CApensation 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 v
work is not commenced within 180 days from date of issuance of
permit, or cessation of work for 180 days will subject permit to cancellat
I certify that I have read this application and state that the above information
correct. I agree to comply with all City, and State laws relating to the buildin
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
„Signature (Owner/Agent)-'-`'�f zw^--.- Date,
BUILDING PERMIT PERMIT#
DATE VALUATION ^. - - . LOT 0104--2M TRACT
JOB SITE
ADDRESS
OWNER
MIZ 110M, LUCAS,
.76ti520 w.rr MR,Lf,.+T ,A V WLTE
'LA Q070M CA. 92253
USE OF PERMIT
TLtMBWO
13-RTY1 Ply T.dt+14KAWAAiDCYM •. SZWkrIZ ifJi. KAJ-P
VALUATION
APN
NEER
84045 CAT3.�. 014 RD. 91`�{ 10, CA 912201
1'ALMV=1 10a Cis. 92261.
(70)346.2793 MIX 342
2,000100 1118
P=Aff11 by"C' SUMMARY
PLUMD)NO R,F '- :3YMP 101-000-4.'W,000 $30.00
O , 5: ' . p • ld `.� UC",1':�t�N ti'E N PLAN C'' :EM
P:�,1M1' I E S DITE NOW
DATE l I BY
.S.13O H)
V100
til 30.00
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pale
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 VALLEY WATER DISTRICT
CASH RECEIPT DETAIL �i� �g
Received From: ✓% &_, '
L_.- 1.1 C C _L
Address:
Ll
Account No. 1 ) I
(.. L%1(s)
Service Address — • �.
I''?� 1'' ! F , f
❑ Meter(s)
❑ Service(s)
I
❑ Backflow(s)
O House Lateral(s)
❑ DetectorCheck(s)
O Meter Surcharge
O' Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge _
O Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water 1 Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
O Customer Deposit
O Other
Remarks:
GLCopy to:
Money
Order
G.A. Code
$
TOTAL $
Water Service
Cashier �T_
CVW6-438 (11189)