9806-098 (PLBG)LICENSED CONTRACTOR DECLARATION
��. I*h`ereby affirm under penalty of perjury that I am licensed under provisions of
`F- ~Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
LLi ,' ProfeSsidnals Code, and my License is in full force and effect.
O ch .. License # Lic. Class Exp. Date
LU
ti r�gt f�/�
Z r` D e � Signature of Contractor
J C0 OWNER -BUILDER DECLARATION
W W r` I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ License Law for the following reason:
Z_ ( ) 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).
co() I am exempt under Section
U*) B&P.C. for this reason
N Date Signature of Owner
O0
Z WORKER'S COMPENSATION DECLARATION
C:,
Q Z I hereby affirm under penalty of perjury one of the following declarations:
r - O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W !�= compensation, as provided for by Section 3700 of the Labor Code, for the
mQ performance of the work for which this permit is issued.
Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Lo.
Z permit is issued. My workers' compensation insurance carrier & policy no.' are:
Carrier Policy No.
CIS O :; 3'AI L? I� UNU tiO4ft Z t�i3/i.V9
J (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' compe�pation provisions of Section'37,00 of the Labor
Code,,l shall forthwith comply�with those provisions:
Date a— jam) Applicant I i
w i x
Warning: Failure to secure Workers' Cor ensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
' correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
thea Bove -mentioned property for inspectioan pu� S; - /"
Signature (Owner/Agent) l�>---•.�'��`r + r. A4^D/��'ate m�
BUILDING PERMIT
DATE VALUATION 51,370 (HI, LOT
PERMIT#
9806-098
CONTROL#
TRACT. 7921 921
JOB SITE
ADDRESS 7.3�ii (:u%.� i �`�.`Y 'i t,R.K. APN
OWNER CONTRACTOR/DESIGNER/ENGINEER
Ef) M i:. SHAi3OWFN ECONf.) Sf?l E.R SERV,C H
78310 CHES'1'VTEW'1'tJt PA 130.`ti 102
LA (;1 AN7'A C E1 921125:3 VALM DIRSIM' CA 9226t
(60)346 793 C13L.$ :W2
USE OF PERMIT
Pf,1_IA t i t
8%�4�iEt
` PIAS
JUN 10 1998
t:i �ir''T'iiA1;t' AlV1GU1v}' 1,:Z70A�) I. ..t
ts:`r'!'II!'TS;OM C:09r OF C€ NSTROC"TIONt 1,370.09
PERMIT 111MSlJMMARY
PLU.NIRINO FI!T -- 3EWFA 101-000-419-000 t';�fE.iN►
SI; lFV!TY1'A1., CON -r ?IJIMICIN AND N,AN CT—fiECK S3000
LE S P9E-I AID f -,ERS 1 $0.00
DATE
DATE FINALED I INSPECTOR
�ji
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
POOLS - SPAS
BLOCKWALL APPROVALS
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 //� _
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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
Utitity Notice (Perm);.:
ECONO SEWER SERVICE, INC. • AM MOM OEM
P. o. BOX 192 - 11860 ,
PALM DESERT, CALIF.'92261 I/
(bly) 34b-Z/y3 Or 31ts-//bu
RDER
)
CUSTOMER'S ORDENO.
R
PHONE
MECHANIC
HELPER
STARTING DATE
DAT# COMPLBV/ET 1;]�DTOTAL
AMOUNT
$
BILL TO
ORDER TAKEN BY
ADDRESS
E) DAY WORK
CONTRACT
GIT
C
EXTRA
JOB NAME AND LOCATION
JOB PHONE
fi/(�' 4d No one home Total amount due �"T I billing after Signature —�/�,9 or above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of work
of the above described work
TOTAL MATERIALS
TOTALLABOR
TAX
DAT# COMPLBV/ET 1;]�DTOTAL
AMOUNT
$
fi/(�' 4d No one home Total amount due �"T I billing after Signature —�/�,9 or above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of work
of the above described work
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: b(A %/N
r%q ANO A,)1= A)
Address: 7;R ('
Account No. -
d
KL S fy1E(A.) TE ezz
�•
_33
�(_Sb
Service Address j
,. 1Lot(s) _ p
(^fit / VI� _
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Laterals)
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
M T� irn nn ChnrnP
❑ Uncollected Account -Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
n f`. CtnmPr nPnnQit
❑ Other
Remarks:
CA %),;15 3
Tract C .,
G.A. Code
TOTAL
I:I
,Copy to: ;,. i li
Cash Water Service
Check = C_ U5 r Ca
Money sl;j
shier /
Order CVWD-43& (11189)