8019 (PLBG)LICENSED CONTRACTOR DECLARATION
ylHereby 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
tSil(1 cil C -4f, ^- /110/5 V901
V/Date 7ASignature of Contractorj�'
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 ) 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
pVI
ormance of the work for which this permit is issued.
have and will maintain workers' compensation insurance, as required by
Sion 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.
S s A'1VE FO�iC f
(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 df`the Labor
,Eode •sh I forthwith comply with those provisions.
Date: , � � Applicants
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, indemnif�
& 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 inspection purposes.
/Signature (Owner/Agent) I Jt----- le �. � �-_���Date �
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT �(ffi-Z,-1CS TRACT 019
JOB SITE
ADDRESS 5X%5 AV a+MDA NAVA RRO
APN
OWNER -
CONTRACTOR/DESIGNER/ENGINEER
liEpctAX.REA1.: 110R.
RC011,130 SENVI , SEPVV1C'E.
53-945 f'tVENIDA NAVA' IM -0
P.O. BOX, 192
L,k QUfNTA. CA. 922,53
O 'SE!�R'i' CflWZ261
/P*ftl1�`.WOE'
3�
�r�A
\..lJ�r�f 342
USE OF PERMIT
Pi,tlM8
8B MAI CONNECT A14A1r1WN
VlU.LNi.'d ION IigMOO a. i
ESTIMATED ATE.D (.; ' 'f OF MINS RUC:�MN
11500.410
f':ERftIT isEI11 XU:flr MARY
PLUMBING SCE, SEWER 101 -000 -41.9 -NO $30,00
z
` F
tiT\OAI,CONMUCTIONATvRj1'd_-ANCI CK
$3000
LESS ME -PAID FEES
so.fyo
'MAL I'VRIMAT FEES ase7E i TOW
$30.00
xA
RECEIPT�--,' —Xi
DA E
BY
DATE FINALED
INSPECTOR
j,- A
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 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
O.K. for Finish Plaster
Sewer Lateral�/r
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Ap p1 fiances
_ _�'�✓
_
�� �
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
c
Final
Utility Notice (Perm)
COMMENTS:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: .F' n A ('
Address: '7 ; �^ �� l 1t
f > �� P
r�' _ (.
�Jl ,SGi
c r!
(�
Account No. i . ( �i / (�
(T�
Tract_
Service Address r> '> (� `� '- �'
,L�olt(s)
P / r r/ r
/ l / I� r� G.A. Code
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral (s)
❑ DetectorCheck(s)
❑ Meter Surcharge
❑,,,8ranitationCapacity Charge
L�
❑ 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
Jam 00a OMM
ECONO SEWER SERVICE, INC.
P. 0. Box 192 &�?% 11903
PALM DESERT; CALIF. 92261
(619) 346-2793 or 328.7760
TOTAL MATERIALS
DA OF ORD
R
CUSTOMER'S ORDER NO.
PHONE
ME
NIC
HL ER
STARTING DATE
�TOTALAMOUNY
BILL
ORDER TAKEN BY
A E
r/y_
El DAY WORK
v�`/YC/
❑ CONTRACT
EXTRA
C TV 7 '���IIIJJJVVV
GsV
OB .4 AND LOCAT ON
JOB PHONE
Signature
0
L) No one home [-] Total amount due
S for'above work: or
I hereby acknowledge the satisfactory completion
of the above described work
D/Tot&jW0Rg to-'
be mailed after
completion
of work
TOTAL MATERIALS
TOTAL LABOR
TAX
DATE COMPLETED
WORK ORDERED BY .A I
�TOTALAMOUNY
7
Signature
0
L) No one home [-] Total amount due
S for'above work: or
I hereby acknowledge the satisfactory completion
of the above described work
D/Tot&jW0Rg to-'
be mailed after
completion
of work
TOTAL MATERIALS
TOTAL LABOR
TAX
DATE COMPLETED
WORK ORDERED BY .A I
�TOTALAMOUNY
Signature
0
L) No one home [-] Total amount due
S for'above work: or
I hereby acknowledge the satisfactory completion
of the above described work
D/Tot&jW0Rg to-'
be mailed after
completion
of work