9901-139 (PLBG)^LICENSED CONTRACTOR DECLARATION
" 14herekiy.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
�3i3,33
AB
Date Signature of Contractor C. _
OWNER -BUILDER DECLARATION t '
I hereby affirm under penalty of perjury that I am exempt -from the Contractor's
License Law for the following reason: )f
( ) I, as owner of the property, or my employees with wage] 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
Sec( ) I have and will maintain workers' compensation insurance, as required by
tion 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.
Siia 40 li1.13 t
(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 df Section 3700 of the Labor
Code, I shall forthwith complynWi
t ose provisions
j�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
correc�,l 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 prt
rgpeSy-for;inspection urposes. c�
/Signature (Owner/Agent) i `' Date" t r
PERMIT# '
BUILDING PERMIT
DATE VALUATION LOT TRACT 'P
JOB SITE .
APN I ' "!{+'''�' ;Y•.f`
ADDRESS 51-200 AW -1410A VINLASCO
^
OWNER
CONTRACTOR/DESIGNER/ENGINEER 1
' r
ALAN .A. & SMIR-LENE X11 1RITT
Ne. ;
5I-200AVFNIDA VE.LASCO
P.0, BOX 1555
1,A QC INTA. CA Q253
LA QWN]'A fit 92253
(760)34042126 ORI -f8 25213
USE OF PERMIT
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VAi.,MMON- 1.500.00 iota
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,Uf STI MATTM CMT OF C',C)NISTRUff ION
1,500."
'l�:l�I4rtI 1 S'tJM"Ry
P!.£ff49BINO FEL — SF'VIPf<ili. 301•1000-419-000 S3lf.tatl
LESS PREPAID FEES
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SX).00
CEIPT t ' !DATE
By °
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
I
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
OX 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
eExterior Receptacles
JIG.F.I.
ISmoke Detectors
JkTemp. Use of Power
"Final
Utility Notice (Perm)
COMMENTS:
Received Fr q
'y
.,- -I f.-
Address: .0;
F. Account No.
Lot(
Service Address
COACHELLA VALLEY WATER DISTRICT
0 Meter(s)
CASH RECEIPT DETAIL
Received Fr q
'y
.,- -I f.-
Address: .0;
F. Account No.
Lot(
Service Address
0 Meter(s)
0 Service(s)
0 Backflow(s)
0 House Laterals)
0 Detector Check(s)
0 Meter Surcharge
Sanitation Capacity Charge
0 W.S.B.F.C.
0 Temporary Construction Meter*
0 Turn on Charge
0 Uncollected Account -Name
0 Inspection Fee-Tract-
ee TractFee
Fee-
0 Plan Check Fees Water I Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
0 Other
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Remarks:
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2502 Morongo Trail
Palm Springs, CA 92264
(760) 327-8859
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PAYMENT DUE UPON RECEIPT