9606-163 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section -1000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect. ;
License # Lic,..((Glas Exp. Date
A.9 li:itl
Date t 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:
( ) 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 rAue& My (workers' compensation. insurance carr e0V'poll cy 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 Calif• mi and agree that if I shout become
6bject to the workers' compensati6n
'q a, of Section 3700 of the Labor
Code„I's Iljferthwith comply with thos�e����sion�
Date: p� Applicant A � vii
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his•
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void. if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comp' with all Ciity, and State laws relating to the building
construction, and hereby authorize.representatives of t is City to enter upon
the above-mentioned property for iinspection purposes.
Signature (Owner/Agent) ate E a
,) -ci UI�LDING PERMIT PERMIT C°NTROL#
3
”
DATE 6!• 16 VALUATION . SJ,,4)0J),a0 LOT TRACTJOB
SITE
ADDRESS 5.1-870 AVIi JUARZ
APN
OWNER
CONTRACTOR
A��(*`fig(( 7}+
IvfllhS�.(f...i'�lC,
y//ENGINEER
y/{DESIGNER
i�7.6J1v}l'll,,•!i`!ti n.
PO BOX -555
51•00I EISk;NI•fOVltM DR,
LA. QUIN.i'A. CA 92253
1..A QUINTA CA, 92253
%4-1.139
(619Y564-1358 CSUI L526
USE OF PERMIT
ABON, SUPTIC (XYNNfiC.T TO SEWMI, ,
�:.ti fIMA.'1TED COST OF CONST RUCTION
�,SiIDi�.d1i1
PF,,RtM.rf FCC. SiTMMARY
PT,VMVM10.Ft$, --.'$EVER • . • .10M3()i}-t'I.T,9.000
x :sUl3,'f'+ I'AL 60N S`{'RT111211: NI AN:D MAN CHECK
$30.00
LESS IRE -I AID VEI S
$0,00
Q "kAI.,'Ii�1T'>H.;S DOE Rs�11�(1391,(i4)
Jut p
RECEIPT
Y
DATE FINALED
INSPECTOR
r2d
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
OX to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail 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 I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final '
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX: for Finish Plaster
Sewer Lateral
Pool Cover .
Sewer Connection 67
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final G
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:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received Fro : &r,j
Address: av g •
Account No. �� ( • " Lot(s)
Service Address
❑ Meter(s)
Ilh
Tract
G.A. Code
a
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge C� a
Q-�ganitation Capacity Charge ► C a l o� S. U J
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
rr TOTAL a C5 C-)
S• J
Remarks: .� i>�_ r. t ? C 4 -i`(
❑COPY to:
Cash WaterServic
Check
ey Cashier
Order
CVWD-436 (11189)
:all "lu 10 ["&I-qivjLojMw
Is 1141
2502 Morongo Trail
Palm Springs, CA 92264 Ns 18712
(619)327-8859
SOLD TO
SAS -1 SMAN
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TERMS
SHIPPED TO
!EfTREET No
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STATE
-4 -41 -*e () I —
---
STREET NO.
--
CITY
STATS
ZIP
CITY
STATE zip
CUSTOMER ORDER
SAS -1 SMAN
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TERMS
DATE
/IVY
PAYMENT DUE UPON RECEIPT,..