9512-048 (PLBG)LICENSED CONTRACTOR DECLARATION
!hereby affirm 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 that I am exempt from the Contractor's License Law for the
followin ,reason:
(�Ias 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).
O I am exempt under Section B&P.C. for this reason
-Date Signature ofOwner/° 'i r
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:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100.00 or less).
( 0!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: .�.i->" k—Applicant/ �t,._/'�'',' ' � � fg•�-'
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 I
above-mentioned property for inspection purposes. ,
mature (Owner/Agerp Dade � '
A"' _
BUILDING PERMIT
PERMITyi��
DATE >EL kYy-3
VALUATION A9'0t LOT
TRACT
JOB SITE ADDRESS 54-202 AVE.VEWCO
APN 774-.215-010
OWNER
CONTRACTOR
OWNERBUILDER
DER
A3trHUI, W4 & FLOHNCE: BUS"TAMA
54202 VENIDA VELASCO
LA QUiNTA CA 92253
CBi:.#
DESIGNERIENGINEER
USE OF PERMI13Lt„ T�.1e1NC
SEWS CONNWT
FEE DESCRIPTION
FEES
CONTRACT AMOLM I,000A0 LS
'ESTIMATED COSH' OF CONI STRUC`I ION
I'mo. 0)
PERMIT FEE; SUMMARY
PLUMBING FEE .-= SE'W'ER 101,000-A19-000 $30.00
SUIS -TOTAL CONSTRUC ION AND PLAN CHECK
$30.00
'�U ^ LESS PREPAID FEES
$0,00
CCG, <// VAL.VE R11 I `EE; DUE NOW
530.00
B `�� 1995
'kECVJPT
DATE v�
BY
DATE FINALED
INSPECTOR
t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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 Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I 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:
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)
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i
COACHELLA VALLEY WATER DISTRICTC-
CASH RECEIPT DETAIL
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Date'
Received From:
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Address: d • 9j
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Account N -'
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Service Address ti L
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G.A. Coda
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❑ Meter(s)
$
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❑ Service(s)
❑ Backflow(s)
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❑ House Lateral(s)
❑ Detector Checks)
❑ Meter Surcharge
-
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Sanitation Capacity Charge
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❑ WS.B.F.C.
-
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❑ Temporary Construction Meter
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❑ Tum on Charge _
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❑ Uncollected Account - Name
-
❑ InspectionFee- Tract -
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Fee -
0 Plan Check Fees Water I Sewer -
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Tract -
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❑ Bond Payment - A.D. -
Bond
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Assmt
❑ Customer Deposit
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❑ Other
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TOTAL S
Remarks:
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.❑copy to:
Water Service o,
Cash
Check
Money
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Cashier
Order
cCMD-43801189)rsahuasl
e,
VALLEY WIDE PIMPING SERVICE
:100 , S. Sunrise, Way . Suite 133
PALM SPRINGS, CA 92262
(619) 322-2400 (619) 347-3545
"YOUR`WASTE .IS OUR PROBLEM"
SOLD B
a�✓
DATE '
/ _19- 91'
NAME
Uf lD -
ADDRESS/- -
/I v_c (/ �lCo
PHONE
Da G .
CITY
G6. 2-2
010. CASH ❑ CHARGE ❑ MERCHANDISE RETURNED
❑ C.O.D. ❑ PAID OUT ❑ PAID ON ACCOUNT
QTY.
DESCRIPTION
PRICE
AMOUNT
1
�a GU
C_X-
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5
6
7
l
8
9
10
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12
13
14
15JE-ADDED.
HIS BILL MUST BE PAID WITHIN 7 DAYS
F INVOICE DATE OR -I%% INTERE
16
RECEIVED
TOTAL
,
THANK YOU
Contents: 40% Pre -Consumer • 10% Post -Consumer
ACV
78-105 CALLE ESTADO - LA QUINTA, CALIFORNIA 92253 (619) 564.2246
September -24, 1986
To Whom It May Concern:
The room addition 'constructed on the south/east corner .of the structure`
located at 54-202 'Avenida Velasco is no closer -to the south property line
than the original structure.
If the property were to be less than 50% destroyed a building permit would
be allowed.to rebuild the -structure at its present location.
Very truly yours,
BUILDING DEPARTMENT
Tom Hartung
Building Official
TH:psn
MAILING ADDRESS P.O. BOX 1504 - `LA QUINTA, CALIFORNIA 92253