9607-058 (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. ClassExp. Date
4f W61 C -a'. � IV31/97
Date ' 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. .
X 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 isisAued2 M,yj1wprkers' compensation insurance carrier .pglipy 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 Califorhiaandagreethat if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply witht ose,oroisto s.
<Date: I F Applicant
Warning: Failure to secure Workers' Compen ation coverage is unlawful and
shall subject an employer to criminal penalties, d 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 'orr 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 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,inspeAtion purposes.
<Signature wneiiAgent) i '`� �- Y`""""� Date ~
PERMIT# CONTROL#
BUILDING PERMIT
9607_0.14I 3727
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS .514"0E1,OrI�NA.ii.�� .Izl��:itl;.�
APN
'773.-155-007
OWNER
CONTRACTOR /DESIGNER
��wwyy ( fqi
r/ENGINEER
SERVICE
51890 A VE141DA JUME7,
84035 CABAWN RD.
R4D10C".A 92243
PALM V)RSE T CS 9'12261
CBL # 3432
USE OF PERMIT
PUJIMANO
S!'stkER CC)
k:t,iiv'.MfWlI' AMOUN`f' ii0(;,tsif J. >
FUS'L•3lVIMCD CONT 01? CON:S'I,'AMCI'i'ON
'It6i).Eiil '
SNUMMARY
�i,i214t13AN(; I+'F'R .Lt}1-Lf)iJ-AY,�(14Q •5:10.00
' .:.F... sud".- IJCT10NAND-PLkmcnr.:cK. cnr.:c
S.70,00
L,.lv .P FrI''}t ll) iF X
"j;0.00
JUL, 2 2 1996 '
BY
RECEIPT
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 Wali 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 Pibg. 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
AppjiaM
Final
Final !�
Utility Notice (Gas)
ELECTRICAL APPROV LS
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 From:
f C O" O X IJJ�'f S (�i 1 C Date:
Address:
Lots) Tract
Account No. _
Service Address e v'1 (J A G Y A 1 G.A. Code
1
❑ Meter(s) $
i❑ Servlce(s)
If ❑ Backflow(s)
❑ House Lateral(s)
O DetectorCheck(s)
❑ Meter Surcharge
�nitation Capacity Charge
O W.S.B.F.C.
O Temporary Construction Meter
O Turn on Charge
O Uncollected Account- Name
O Inspection Fee - Tract -
Fee -
O Plan Check Fees Water I Sewer -
Tract -
O Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other h
I L- TOTAL $ j
Remarks: �� 1 I \/1/� 6,
❑Copy to:
Water Service
Cash
Check (o �.' >; r F;,:
' Cashier
Money
Order ,, CVWD-438(11189)
.-.,,�.,�..;.:,-' _. / c.,...f - 17L::.i.L`• • �F v,:- _ �•�.:: ...re...y<.�:'• - - --.i.._..::�:,.cr:.s,�c....::..:.t .,2
I ft
DATE
FAX Tu
FAXNO
MU. Or PAC,*I$
PHONE
FAX NO
P.O. Box 19i
PALM DESERT, CALIFORN A. 91251
PHONE 328.7760 345-2]93
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Fi,yl-irul i£"+iMS NIEr !Q PAYS Tr pi: DATe
�TD1At
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O STATEMFNIt LLA ! -- _ - -- .
DOTAL MOUt#T I �
rf l.a rn t o rcA j Tatar c.movpt dve (- Totai t
-
".
for above; work: 4I
"• `s`�.j,�L be molgd aftor
! h:r. rock VA" - (I p :tir:hctory Compladan complauan
of at tcnt`ed work Of work
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