9901-057 (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
0 .W Professionals Code, and my License is in full force and effect.
=) ch License # Lic. Class Exp. Date
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lap 1. 59 C42 v29/00
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Z r_ke ate f Signature of Contractor Y
CO 0 �
J U C:) OWNER -BUILDER DECLARATION
W WW r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) 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).
LO
( ) I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner
CI)CL Q WORKER'S COMPENSATION DECLARATION
p 2
CcI hereby affirm under penalty of perjury one of the following declarations:
LO O () 1 have and will maintain a certificate of consent to self insure for workers'
X W LL compensation, as provided for by Section '3700 of the Labor Code, for the
�
Q 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
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
,It Z Carrier Policy No.
°�D v(3LDFh'EAt»IX INS, IM 4•+�f�''x;-11,'0
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(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 forthwith comply with those provisions.
Date:/ , �r ri Applicant—/
t + ,r r l i / , f
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).f _ Date Z
BUILDING PERMIT PERMIT#
99i114157
DATE VALUATION LOT TRACT
JO SITE
ADDRESS jn-i.tAi f� Y 1 it Y Lt�'. CO APN 773424-0,19
424-0,19
OWNER CONTRACTOR/DESIGNER/ENGINEER
SOMA .S ANCHEZ FCONO SEWER tiF.: VICE
5210AWNIDA VELASC,O 8,4035 C"AZON Itis. IN D10, GA 02201
LA. CRNTA CA, 922,5,3 PALM UESEWV G.A.. 92261
(760)346-2793 CBiA 342
USE OF PERMIT
PL IJAMNO
SEPT IC ABANDON, SEVM CONMiC T �1..0- VIOD PROJECT N-4 $-iU)
i,
COIN ARA%v'.i Al"+ri`iUNT 11.5000.00.LS
A
(F, ��yyaa�'AA,�,rr,.ry, y��s :� X.u�r�ii.�ri4i2'C..1l�C11)\..►.l'�rA �1FCaM,'S�; aRUCIIM14 Je5010.00
S�.f�„.RMI R PCE, E, /9UMIN`AR MY
PLUMBING.FEE SEWER 101-000-4194)00 $30. ()f) 0.()q
Lit M -Tar -Al, C0_ NS RI TC_'TION ANT) PLAN CI•it:CK "on
LESS PRE -PAID PEES $0.00
£OTA1. PCRI i1' IT MKS Ol.IE NOW I S.1101011)
RECEIPT I DATE I BY i) 11 1 DATE FINALED I 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
OX to Wrap
F.A.U. -
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 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 Pibg. 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 —
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
Exterior Receptacles
G.F.I. ,
Smoke Detectors ,
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
ECONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
JOB WORK Oa[�a
%/VV/ JYV-G/7J \/OV/ JLO-//OV
DATE OF ORDER
FAX (760) 347-4978
TOTALLABOR
CUSTOMER'S ORDER NO.
PHONE
MECH C
HELPER
STARTING DATE
BILL TO / ^
ORDER TAKEN BY
ADDRESS
TOTAL AMOUNT
��
❑ DAY WORK
❑ CONTRACT
CITY ,
❑ EXTRA
JOB NAME AND rOCATION
JOB PHONE
DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
3" PER MONTH CHARGE AFTER 30 DAYS
Signature `for above work: or be mailed after
T—` completion
I hereby acknowledge the satisfactory completion of work
of the above described work.
TOTAL MATERIALS
TOTALLABOR
PLEASE PAY FROM THIS INVOICE
11 RE MAIII En
TAX
DATgMPL E
WOR RED BY
TOTAL AMOUNT
$OOF
%��• E] No one home
Total amount due ❑Tot I billing to
Signature `for above work: or be mailed after
T—` completion
I hereby acknowledge the satisfactory completion of work
of the above described work.