9908-201 (PLBG)LICENSED CONTRACTOR DECLARATION
,I hereby affirm under penalty of perjury that I am licensed under provisions of
_ Cbapter.9.(commencing with Section 7000) of Division 3 of the. Business and
Pr-ofessionals Code, and my License is. in full force and effect.
- Ugense # Lic. Class Exp. Date
746154
ate,19, — "Y 9_Si6riature Of Contractordo
OWNER -BUILDER DECLARATION •
I hereby affirm under penalty of perjury that I am exempt from the Contractor's "
License Law for the following reason: • Ir
( ) - I, as owner of the property, or my employees with,wages'as their..
"sole
compensation, will do the work; and the structure is not intendedtor 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). .
O 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.workem'
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:
Carrier/ Policy No. '
. �'JRiB,�iS�A'Y [r.J4:am •atl,,y., •• ;'1 VI.6 . i•I�b'..tt,,S(JKlii
(This section need not bd 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 . !'lAppllcant ' �"
IVI
Warning: Failure to secure" Workers'.Compensation coverage is unlawful and
shall subject 66 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' subjectto '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 ag.pe 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)' ld` Date
BUILDING PERMIT
PERMIT#
DATE LOT
TRACT,
yy 4C/199VALUATION ��+��',yyp{�g��SL
J.
ADDRESS RRZ-590,AVLWI'.D VEuLAII�;OJOB SITE
OWNER
CONTRACTOR/DESIGNER/ENGINEER _
P.O. BOX 134
84035 C.ABAZOIN iLD::1NDIO, CA 92201.
LAQUINTA. A,"A 92253
15A0.<M DESER3'
CA
9126€
iaeil}�lSC�1^r+�3
��'M.4
34`.2
USE OF PERMIT
PL,UNM°l'e G .
i
VALE:{Ann
- .. yi��'I'r'2 A'6 ED �'41VST
- .'M:YtiJ.7, id $.6fi. COST
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(W Pt INSt'4'�C6'1!�:i'�"'R'. HON, �'
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PL( MIBINO FEE — 51 . 1 U 1 • CKItr,•419-M S-xi.n4
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3UG?^-'•.Q¢�if..t�.2.. �i{.JA"a �.T:1.g{}:Q.4v :fi};.'A`+7„i ?y"k.,.;�p w. CK V -
,�es4�. 00
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pr".Amur nesalve, Now
S30.0
RECEIPT
DATE1
BY
DATE FINALED
INSPECTOR
51 .
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 over
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
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
Utility Notice (Perm)
C_OACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: V a Imo►f v,-,
Address: P%0 &UIA3 i4�-
,417
Flu
Account No. ,. / Lot(s)`' per_
Service Address "" .a[� ► t �✓} -"' `1
❑ Meter(s) — —
❑ Service(s)
❑ Backflow(s)
74460
Date: -Z 6 if i
❑ House Laterals)
❑ DetectorCheck(s)
❑ Meter Surcharge ----- p�
b --Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account -Name
❑ Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water ! Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit —
❑ Other
' J
TOTAL $ �_
Remarks Jl �.. °)t! %� !f /� %.^y- r1 71 1_j
Water Service
Cashier"`
'-•s,,;, �• / 1� CVWD-438(11189)