0107-290 (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
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 i 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:
Carter Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
,(I) 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 prQvisions>
Date: `". '%.�• t Applicant-
Warning:
pplicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Buildirig and Safety.,,
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold, harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes. null and void if
work is not commenced within 180 days from date of issuance of such tt
permit, or cessation of work for 180 days will subject permit to cancellation. i
I certify that I have read this application and state that the above information is ( '
correct. I agree to comply with all City, and State laws relating to the building i
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) '''. �" Date
BUILDING PER r'IIT PERMIT#
DATE VALUATION LOT ..j TRACT
0 <9„�C' 711A'IE &V�3.C#f F
JOB SITE W
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�Vf�1
"bO.wKA�T.ALE�
J'BLA►D:ILO
-.3 55
LA QWNTA C—A ,r9i 22535
USE OF PERMIT
5MER NIVA IT
VALUATION
IMM, TATED COST OF COMIRUCnON
.MM$Lffa F".. bV /iMARY
VAL AIM.MO FE1 .., 81: .R 101.0XV-419-00 3
UP -1,19 PRE -PAM PERIS
$0.00
- r 'F. T .IC W f.[b9Y1L.4 ,i' o.F+L4 1' X 6.�.M1..ES tiJ T7'
M.00
JUL 30 2001
RECEIPT `e iti�C�
OgT/E ' %
BYE
DATE FINALED
INSPECTOR
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 Wail 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
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
COMMENTS:
E.(AD 1? oN �¢..s� 8
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS -
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)
COACHELLA "LLEY WATER DISTRICT
('I CASH RECEIPT DETAIL
Received From: /J;- ( j2M
t3
Address:
Account No. �� , Lots)
Service Address
❑ Meter(s)
' ❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s) '
❑ DetectorCheck(s)
❑ Meter Surcharge
U,55iitation Capacity Charge
❑ W.S.B.F.C.
❑ truction Meter
r` ❑ Turn on Charge
`.` ❑' Uncollected Account -Nam
i'
❑ Inspection Fee- Tract-
Fee
ract-Fee -
f
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - tBond_
Assmt.
• ' ❑ Customer Deposit
.:' ❑ Other
--- _4V.
I.
Remarks: _
N2 .80737
Tract
r_ a f ..A.
TOTAL $
,,.w6py to:
r.
Cash Water Service
r' Check
Money 4. ,1.
Cashier
Order _
438 (11189)
V
C�1
P.O. Box 1504
78-495 CALLS TAMPICO
LA QUINTA, CALIFORNIA 92253
September 18, 2000
To: Whom it may concern
RE: 51-355 CALLE_ILOILO
(7 60) 777-7000
(TDD) (760) 777-1227
Re: Assessment District 2000-1, Phase VI Improvements -Areas A, B, C & D
The Property Owner: WILLIAM T. BUFFIN APN 769-114-017
is located within the City's current sewer assessment district. The City anticipates construction of
sewer facilities within the referenced project limits beginning in mid to late October 2000 and
expected to be completed in late May 2001. If you have any questions regarding the project please
don't hesitate to contact me immediately at 777-7045.
Sincerely,
J M. Freeland
Senior Engineer
c: Tom Berg, B&A
Project File 98-19A,B,C&D
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