9712-104 (PLBG)04
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LICENSED CONTRACTOR DECLARATION
v 'iheryaffirm 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
C-12 V
/ate v', f- Signature of Contracto
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 issued. My workers' compensation insurance carrier & policy 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 California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall orthwith comply with trovisions.
yDate: d,��A -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
t e above-mentioned property for inspection p�uC oses.
gnature (Owner/Agent) a a/� • _ F' Date ; 7
CONTROL#
BUILDING PERMIT PERMIT 1717-
04
DATE 1 U23/97 VALUATION $I,14fll),00 LOT TRACT ; C C
ADDRESS 51-i5" ;�VENIDA Cl.��t�l�I'lE' Zvv
JOB SITE
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Q'UIN11M C I1AIIAXTA
A-1 rX 8'PO L. SERV10:1, !NC!
4352" JIWEDA. OR.
16819 JAT- t'C.J? NIORe�t�J<"".iii fti).
SAN 1J1.1:GO C.ti 92124
J' ESUXI' JOU V SPRINGt (.A 92240
rr31+ai3 -687�
USE OF PERMIT
R1
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;sdEANU'Ji VCR SUMMARY
A�
DEC 2 3 1997
fiY'LA QUIN 'A
•
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4
Si B -1110 M., )N ANT.) PLAN' (;'!4FC'K
nn
1 E ,A ,Ing -PAA) 174 Is
40O.Qi}
LFa!
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1
RECEIPT
DATE
BY /
DATE FINALEDINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
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 ( {,j
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) d
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
f
Final
Utility Notice (Perm)
COMMENTS:
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am.licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division43 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
266214 C42.
Date Signature of Contractor
OWNER -BUILDER DECLARATION
J2Q
I hereby affirm under penalty. of perjury that l 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).`
() Lam 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-iAsure 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.
STATE f "D 0:6970005269
(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,1 shall forthwith comply with those provisions.
Date: AoDlicant
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) Date
BUILDING PERMIT
DATE VALUATION LOT
12/23/97 $1,800.00
PERMIT # CONTROL #'
971.2;1.04 TRACT 6496
JOB SITE APN
ADDRESS 51-89(1 A VENIDA CORTEZ 773-153-008
OWNER CONTRACTOR/DESIGNER/ENGINEER
QU111MN C 11ABANTA A-1 CESSPOOL SER'V'ICE, TNC
4352 RUEDA, DR 168191:M LE MORONGO :RD.
SAN DIEGO CA 92.124 DESERT HOT SPRINQ CA. 92240
(61.9)329.687-1 %3L0 . 386
I USE OF PERMIT
SERTIC ABA7 DO-rq, SFW -ER C014IV-C l .
4 rllLUA.TI(OBi
1,800.00 LS
ESTt'�`�'It�,"1 11:f) COSTOF Cf MURUCTION i,sll1,00
P1ERNUT FEE SUMMARY
PLUNIE1CNO FTH -- SEWER .10.4-000-419-()00 $300)
v
SUB i arAL CONSTRUC CION AND PLAN CHECK $30.00
LESS PRE' -PAW FEES 50.010
i
TOTAL, f'kAMIT FEES OL►F NOW' $30.00
I RECEIPT I DATE I BY I DATE FINALED I INSPECTOR
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 PI. Test
Final 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
94,
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:
v
��..�pv'-:16.,�. �..v.'k�:•�vc?ai','+K. ��XaP.g�Ci�. rte'-+�ctsyy,:A �;r.vi�vY iC �' � '--'R�c-...v-..-+..-.,.__.moo..-r, �'^
COACHELLA VALLEY WATER DISTRICT t c
CASH RECEIPT DETAIL 19
j Received From: Tl%ELLZ, iA� ,- 3 _ r sL- �k /
�`? ���07�-17 i
Address: X:Z ii`ICitj 1 DiI IG/'y `'•t`-;=�i\i r,E 4,4jb.i ( L,
AccountNo. Lot(s)
Service Address f, ! - 2i ',) 44/1-'71J- PC e l c
Tract
7 G.A. Code .
❑ Meter(s) $ ;
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Tum 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
TOTAL
/Remarks:
77
IJ Copy to: .(1ljl - Ila p
Cash Water Service
Check ,
Money '� l �� Cashlerzm'
Order
_ CVWD-438(11189)