9605-064 (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. Class Exp. Date
Date , 'Signature of Contractor ,>A \j1
t
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).
( ) 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:
O 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 3 0t a1OX Code, for the performance of the, WQr for which this
permit is'i rkers' compensation insurance c�rh;&1'`�iy 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 C nla, and agree that if I hould become
subjgct to the workers' comperprovisions of Section 37T of 'the Labor
Code, I shall forthwith comply wit rovisions.
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 condition's 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 cessat of work for 180. days will subject permit to cancellation.
certify that I have.read this application and state that the above'information is
correct. I agree to �mply with all City, and State laws relating to the building
construction, and 6.6by-lal fio`ri a representatives of this City to enter upon
the above-mentioned 'prope for inspection purNoses. i
Signature (Owner/Agent)-"- Dater �'✓
BUILDING PERMIT PERMR+� °°NTR°`#
`'"��' 3315
DATE VALUATION $1.4160.11M LOT TRACT
JOB SITE
ADDRESS 53- 540 ,k F: CO MI N
AP
OWNER CONTRACTOR / DESIGNER / ENGINEER
Pt!? ICIz A91'M111L,1°tJL,
53-a40 A:dl C;i::i.R11Z 51 -Girl U ISENHOW ER DR,
t,A QE 1?fl'A LA c; UIN'EA 4CA 92253
(�15115it4.!_33It C'}iLff r'�^t,
USE OF PERMIT
i}LO NIJ31 NG
Sh Wig( tf[:►(DK UP
Mll'IMATEU COST OF d' ON!sTRUC'I'10N 3,Hi}ib.tlSb
PERMITFEC C sa!MMAXV
P'i,i lNtAANG EI FF -., S1 WER tfft -(►( ).,119.000
CO
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SUB -TOTAL CON,SI`RUCMOW ANLL FSI AIN CHECK
I f Ss PftC?-E'AID FEES
a $0.0o
TOTAI, PERM IT .1;'ii1,P..51 CAM NOW $30.0 0,.:
RECEIPT I DATE I BY - I DATE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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 P[bg. 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
dw— AV
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
RoughMiring
Low Voltage Wiring;
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Received From L.L "" t L
Address: �J4 - 1 31; L -o Y.. -a I � � a -".t` � e
Account N Lot(s)
Service.Address TU , e Y -A l P1 D {
❑ Meter(s)'
❑ Service(s)
Backflow(s)
O HouseLateral(s)
❑ Detector Check(s)
❑ Motor Surcharge �/--�-
]�itation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -.
Fee -
❑ Plan Check Fees Water [Sewer -
Tract -
❑ Bond Payment - A.D. --Bond
Assmt.
❑ Customer Deposit
❑ Olher
Remarks:
❑ Copy to:
Cash
Check
Money
Order
L.�
G.A. Code
s
CMD -438011891
SANCO
PUMPING SERVICE )/�
1
2502 Morongo Trail
Palm Springs, CA 92264
(619)327-8859
N! 10243
SOLD TO
SHIPPED TO
STREET NO. /A''� STATE
STREET NO.
DATE
CITY STATE ZIP
CITY 8 A TE IP
CUSTOMER ORDER
S LESMAN
TERMS
DATE
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PAYMENT DUE UPON RECEIPT