0208-020 (PLBG)- LICENSED CONTRACTOR DECLARATION
`I herebyiaffirm under penalty of perjury that I am licensed under provisions of
Chapter ��(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
• 1
eD tSignature of Contractor'�-
�{ •a�7 �r -�
T-
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 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
perforanance of the work for which this permit is issued.
(ij 1 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:
Carver 'V'.IR< III A SURM C Policy No. MOWN?
(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 provision's. f
Date:'Z S3, a '0;—' Applicant ; IL•.Z_ �� ...
/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. s
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 authorise representatives of this City to enter upon ; 3
the above-mentioned propetty,for inspection purposes -6
/i nature (Owner/A ent) /'� `may % 'r Date ,
BUILDING PERMIT
PERMIT#
DATE Dmirx VALUATION 01"M LOT
TRACTJOB
SITE
ADDRESS .5.A ,6.9 fBu.G.LoJD 9�63�t.2la48C0
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
53_686AV"=D VWA`1C0
3K0:1AWEA17P.yi1E
LA iZUWA C.A. 92253
gAXk rJRA . Crff �:�,:.�
92234
{70)2124.1911 ua"L#
uq
USE OF PERMIT
��..ts�:it3• 1,
SEPTIC MANDOMMENTSEWER 1•tOOK-UP
VALUATION
i's
E51`3;OWED COST OF OOMMUMON
PLUMBIN-0 fre4Z ' MM 101.000-419-01M
IUD,"
SI -"CO' AL g 0}�t�'I .RtXf'f1 K M1S;) PLAN CENUM UM
$10.00
All 0 z ?a0?
Cw0 LAOU1Nrq
RECEIPT• BY
Dq FI LED INSPECTOR
oAL
INSPECTION RECORD
OPERATION
DATE
INSPECTOR OPERATION
DATE
TINSPECTOR
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. I Grills
Fireplace T.O. ; Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
I 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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines 7 !JZ
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
Utility Notice (Perm)
"!r `? - !+r . , V'L .. � �Y�..f' � Asn• {r
Morong o Trail
� r' PUMPING SERVICE ti
''Y Palm Springs, CA 92264
(760)1327-8859
SOL
SHIPPE .
STREET NO,
STAB E
.STREET NO.
5 3G S'jw
C/I Tyj`/� (//y�\(
STA (TEE,'1 ZIP
CITY r .S ATE ZIP
-CUSTOMER.ORDER
V /D cep
�>
PAYMENT DUE UPON RECEI
Ku•!•�-;r. .".:. 1. �'. �';;s,..'IK'!vf.Ju� .,.._x ._.�..� .h�!'.ir,S:�c•4.a...l N�7E:'�7.... _`fi'.� .....zwi._..7.�.i.�.i �. ait•.r
COACHELLA VALLEY
WATER DISTRICT
CASH RECEIPT DETAIL /
9 10
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I Received From:
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.
Date:
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Address: "`' t a` (V '\ :CA
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AccountNo. : 4' ! i=
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Lot(s) s,.
i i 1' t • •... t. Tract �,• • �.�
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• Service Address " �•� ' i=
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`'a c-- ; '
G.A. Code
k D Meter(s)
❑ Service(s)
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• ❑ Backflows)
I'
D House Lateral(s)
f, ❑ DetectorCheck(s)
❑ Meter Surcharge
`
D"Sanitation Capacity Charge
r
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
D Inspection Fee - Tract -
i
• ee-
Fee-
0
❑ Plan Check Fees Water 1 Sewer -
Tract -
I� ❑ Bond Payment - A.D. - Bond
1
f
j Assmt.
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f❑ Customer Deposit
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❑ Other
17�..�
TOTAL
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Remarks:- ' �. i•
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0C0py to:
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Cash
Water
Service. Ali fr
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Cashier a
Check-
Money
JI
Order
CVWD-438 (11189) .