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LICENSED CONTRACTOR DECLARATION
It I hereby affirm under penalty of perjury that I am licensed under provisions of
rAChapter 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
482180 al C4;_1 11 =12(
15`ate-� 3 Signature of Contractor!
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractorls�
License Law for the following reason:
( ) 1, as owner of the prop6rty, 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).
( ) 1, 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 wPwrAiA0URFTVC Policy No. 00599007M
(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
worker s' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of -,the Labor
,Code,,l shi 4W
_,�,1,1.,fo�,rthv�ith comply withAhose provisions.
D e
at Applic t
Warning: Failure to secure Wo rkers' Con4p6nsation 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 o0iwork 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 autfforize representatives of this City to enter upon
the above-mentioned property for inspection purposes./
&Tig-nature (Owner/Agent)O Date
'k PERMIT#
BUILDING PE '
RAI A I
MVI -138
DATE VALUATION LOT TRACT
01/2*2K szX0.0111-1
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER EN61NEER
ZAP_kC4 0 &N
MIMS UMMIGROMR) CONST
5 3 - 680 F.J. ORI MHOWn DRIVE
3IF703 VIUADRIVE
LA QTJ.-MTrA CA 92253
CATI-MMAL MTY CA 92234
(760)324-1911 MR 769
USE OF PERMIT
PLUMBiNG
SEPTIC TA14K ASAWn.ONMERT -SXWFR HOOK-UP
IMUATIOK Zoom Ls
EFAINUM.0 Mrt OF CONSTRUCHON
PERAHT M- R RMWARY
101-000-419-000
t
JAN 2 4 2003
CITY OF Lik QUINTA
FINANCE DEPT
im-Tdv& CoNnnaffog,mm PL" cfu,7m,�
$30.00
LESS PRE -PAID FFXS
$010.9
PEWIWI MN DUE HOW
$30109
RECEIPT
DAT�/;?
BY
TDATE FINAfD
INSPECTION RECORD
OPERATION
I DATE I
INSPECTOR
OPERATION
I DATE
I 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
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
6derior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
SetBacks
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 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:
us
z
2502 Morongo Trail
Palm Springs, CA 92264
(760) 327-8859
` 2
�E7
10905
SOLD To
SNLESMAN
00��
SHIPPED TO
STREET NO.
STATE
STREET NO.
-3
C TY
STATE
ZIP
CITY STATE ZIP
�< /o.."
"t:�
" e5' -Z -,
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CUSTOMER ORDER
SNLESMAN
00��
-7-
00
PAYMENT DUE UPON RECEIPT
�
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
N?
933-71
Received From:
Date:
Address:
Account No. Lot(.)
Tract
Service Address
G.A. Code
• Meter(s)
$
• Service(s)
• Backflow(s)
• House Lateral(s)
• Detector Check(s)
CJ Meter Surcharge
San ital ion Capacity Charge
CJ W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee - Tract -
Fee -
0 Plan Check Fees Water Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
0 Other
',
TOTAL $
Remarks:
Copy to: 'k
A
Cash
WaterService
Check
Money
Cashier
Order
CVWD-438 (11189)
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