9807-194 (PLBG) (2)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
r}Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
480961 C -4F. 10/31/99
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:
( ) 1, 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 A PrnfasSinnals r.nrla)
( ) 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 Policy No.
STI ATE FUND
(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 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
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 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)
f*_1 !
Date
PERMIT# CONTROL#
BUILDING PERMIT 9807.19
DATE 7t.27/_9S VALUATION &J,. 0(J.00. LOT • TRACT739
JOB SITE ADDRESS :5�-480 AITta!,M AN AVARRO APN M
OWNER CONTRACTOR/DESIGNER/ENGINEER
,53-490 AWNIDA MWtifZit.O P.O. BOX 192
LAQWNFA CA 92253DES)iw CA 9226)1
(7(A134&27-):3 CW.:ff 342
USE OF PEnIAIT
SEPTIC ABANDL14MEW-C SEWER CONNE
VALUATko'N I'M0,00 LS
E. i..illPlP.ty.TTI, - CO S�� OF �l..iJ�:l S R E.SU 4 P<!1'i
RLUMBING: FEE Sf✓th FR 101-000-419-000 $30.00
LJZS8 PRE -PMD FEES
J 1501110. 00
30.W
$0.00
O�A�, ' :�R "g' f+F&wS 1�d1 : NOW I �SOa00
RECEIPT DATE : BY DATE FINALED JINSPECTOR
EI
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��
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:
I
Account No. �� ��' �' I, Lot(s) �� ` �7 Tract_
_ . ,. --- ��--yu3-E' /Vitl f�Q ✓�i� i _ G.A. Code
S
TOTAL
AGGREGATES, INC.
P.O. Box 567, Thousand Palms, CA 92276
•
ECONO SEWER
AGGREGATE
i :REDI-MIX
GEN. OFFICE
343=3111
343-3403
343-3126
ECO140
5348(-) A,",/ E WiVARO
LA OLIINTA t A
TICKET i"
F� C) C I I V ell
4 -fl
FREE UNLOADING TIME: 5 MINUTES PER Yb Rtbi'MIXI�v,15 MINUTES PER LOADi":4 P1`X'_`XM11
DRY MATERIAL"�v CHARGE FOR ADDITIONAUUNLbAbNW
GTEs1.r66 PER MINUTE
§CH.'ARRIW` •ACT. ARRIVE START UNLOAD FIN. UNLOAD L-joB DEPART .,-� TOTA
PLT.ARhl 7 L�Low,mlisi""" tj�-.'ACT.IAIW� .,EXT V_1
7'
HE 6 i tA �b
USE OF, THIS PRODUCT WITHOUT. PROTECTIVE CLOTHING COULD CAUSE180DILY INJURY:, -EVERY EFFORT;,
SHOULD BE TAKEN _TO'AVO1D'C_ON_Tj A_C_ T_,,WITH, SKIN. Wff, bb-Nitli+60A' A A-ATEE-b"O WcbNdkLtE.7'O_R C-OL
&'SfRENG'TH UNLESS FRO0ER.'d'bhING..P'R'Oi CED—
URES'AR FOLLOWED -y,1--'1,'- �it
T
batch I of I 9.50000ds
Scale Zeros: AGGAI OLbs
bESCRIPTION Kl` R L BIN AMOUNT TARGET DESCRIPTION
3/4 ROE'K 2 A6A2 OLb 0 3/8 ROCK
[ON SAND 4i ASA4 -5(!Lb 0 TYPE Illy
SIKA 161 21 ADA3 OOZ, 0 SUPER P —
-CAL, Eft 24 ADA4r 00t. 0 BELL HATER -
X Moist: AGA'j 2.2%
Maximum Add Haterz.
A-1 AGGREGATES INC ."'i WEiGH'M 'ASTER"
Note'V"�,.THIS IS TO CERTIFY- t6i*th6 following "Cles6ri 6d Co'r
he 200 ista
�tn w6ig d measured; bi 6o6At6d;',_a �2 C
' - ' I — h6i
s,. A 92276 by a wei h aisteri��
..j.housands P61i6� eC _d
signature is on'this certificate, who' is a recognized nize aul
accuracy, as pres6ribed by'Chapter ,7,(commencing'w
12700) of Division . 5 of the California Business*and P6
-administered byjh6 Division of Measurement ,�,code, &
the California D60ahment.of F66'd A'nd'A'g-ric�-utlt'U-r-e.",;i
V
BY. DEPUTY: n
MTRL BIN AMOUNT TARGET - DESCRIPTION
I ALAI
OLb
0
W4 SAND
11 CHAT
OLb
0
TYPE 11
E2 ADA2
00Z
0
Ajrx ENTRAIN
17 4TAI
.3336al
333
TANK NATER
CUSTOMER
031576
MTRL BIN AMOUNT TARGET
3 ASA3 27850Lb 27962
12 V'01, 1820Lb. 1786
23 ADA! . 00z 0
16 NTAEN 06al
nes shall be 6o,hside-rod.n.-ad'&when 7"the products hereon are
d on licensed carriers equipment as evidenced by delivery 7her
:s):-�, At thit time title to the products shall pass to buyer.
hot, to hold r A-1 I or any of ib ernployees or carriers liable for.,,..,
ges inside curborproperty line caused by any of t eir -.41 ' 4 A fV,
meni,'6§ I have requested -delivery on the property for the
-ial I isted.,e Additional water added to this concrete will reduce, it;l
y
jih.'!An water.added is at --ustomer's. risk. 'Customer hereby,
to
1 indemnify A'its employees or carrieis from any -,,j' k .
-
11
g fr6ni'such additi6hs
71.4. IF
GALS WATER ADDED Jf,,
TU