9806-075 (PLBG)M 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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
� t tiI AC -42 1@l31iti ,
� i
gate L �- �4� Signature of Contractor` -
4B
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).
( ) 1, 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.
()r I have and will maintain workers' compensation insurance, as required by
Sel`on 3700 of the Labor Code, for the performance of the work for which this
/6ermlt is issued. My workers' compensation insurance carrier & policy no. are:
CarrierSTAMITL'•tx`i) Policy No. 00.16 _f:;.t;IwA0
(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. :' n
Date: 0V Applicants' 11
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 Safetyf `
for a permit subject to the conditions and restrictions set forth on 6is:1r
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.
ignature (Owner/Agent)' ' 71 _ Date •--a ',E`� �
i • BUILDING PERMIT PERMIT# CONTROL#
DATE VALUATION ,0�1�.€ LOT TRACT �i O C�
G �ikoi ( v
JOB SITE 54-390 AV ENI D' A V ELE SCO APN '774-2: 2.4107
ADDRESS
OWNER
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sx@: v�l'vii%C iYvA.iv CONTRACTOR / DESIGNER /@@ENGINEER
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srxY'jvJ7a, Irt, 1-
X4-390 AVENWA V. LASCO P.O.13OX 142
LA C1IIIMI-A CA 972w3 PAI.Al 138SERT CA 92261
(76)3464793 CW 142
USE OF PERMIT
MAMA
w%ui,vrION
1,481.001IS
1,491,00
+I'ERM IT VE''R SIUtb MARY
P11.1iml TINO FFE -- :110XI 11 101-f)f)D-41.9-t )0 $30 c1
0
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JUN 0 8 1998 LESS RRE-1 AID ITUS KOO
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RECEIPT DATE BY/ .ti DATE FINALED INSPECTOR
M- o O Mr
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 8 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
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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
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
t
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Final
Utility Notice (Perm)
Final
COMMENTS:
ECONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
r7r,m 'Aaa.'27faz 17rm g9R.779;n
J00 0 WORE (ORDER
FAX (760) 347-4978
TOTAL MATERIALS
DA&F ORDER p
CUSTOMER'S ORDER NO.
PHONE
MEC}1A�
HELPER
STARTING DATE
BILL /T¢ ♦ �
&4 GO) A>4 �4
ORDER TAKEN BY
ADDS -I1/o
ue'
fj�
�/ I' 7go
❑ DAY WORK
❑ CONTRACT
❑ EXTRA
��
CITY 19
JOB NAME AND LOCATION
JOB PHONE
DESCRIPTION OF WORK PAYMLNI ILKMS NLI lU UATJ rKUM PAIL Vr OLKYIIoL
11/2% PER MONTH CHARGE AFTER 30 DAYS.
Signature
❑ No one home ❑ Total amount due
for above work: or
1 hereby acknowledge the satisfactory completion
of the above described work.
❑ /otal billing to
be mailed after
completion
of work
TOTAL MATERIALS
TOTALLABOR
PLEASE PAY FROM THIS INVOICE.
NO STATEMENT WILL BE MAILED.
TAX
DATE COMPLETEDWORK
ORDERED BY
TOTAL AMOUNT
$ e -
Signature
❑ No one home ❑ Total amount due
for above work: or
1 hereby acknowledge the satisfactory completion
of the above described work.
❑ /otal billing to
be mailed after
completion
of work
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APPLICATION FOR TREE PLANTING
I (we), the undersigned, hereby certify and acknowledge that I (we) have read the application and agree that if trees are required under River-
side County Ordinance No. 457, the applicant agrees to install said trees prior to final inspection. It is understood that no final'Onspaction
will be given until said requirements have been met or exception has been granted by the County. Now, therefore, it is agreed that the prop-
erty owner shall cause the property lines to be surveyed in the event no survey stakes can be found. Further, it is agreed that the County of
Riverside shall assume no responsibility should trees have to be removed due to lot line errors.
�M.iling
wrier'. Name - - I, %% De S iwNF2 Building Perm-- N 3�(� Address L % City
0
�9! �Np�sta`tp _ / e , ip g�� D
Job Address I IR 0 Community
i a..
Legal Description
Assessor's M� ...B.''o,o�k, ,& Page 1-2150 Type Structure ��` ) U
Type.eroil FIs water available Road Dept. Plot Plan No.
Type of existing trees in ro d right-of-way
Trees preferred by applic(1) (�L (3
D to Owne"r's Signature 0,/ /�
Planning Commission Case No.
ROAD DEPARTMENT APPROVAL
Approved species Ceratonia siliqua (Carob) Number of trees 1
Spacing of trees Distance from lot lines: Front 2' in R/W Side
Additional requirements per plot plan on reverse_
Date building and Safety notitied 3/79 S1gnature
Request for hearing: YES ❑
Owner's Signature
(attach additional page if necessary)
(Forward application to Planning Dept. if exception requested)
NO REQUEST FOR HEARING
Planning Dept.
Concur M
D ate
Road Dept.
Non -concur M Explanation
Signature
Concur Non -Concur M
Date Signature
REQUEST FOR HEARING AND COMMITTEE DECISION
Date hearing established Date hearing notice mailed to owner
Approved 0 Disapproved Date Owner notified of decision
Date Building & Safety notified Signature
Final Date Inspector _
Job Address
Requirements for tree planting complied with
Remark s
APPROVAL BY BUILDING INSPECTOR
Building Permit No
_ommunity.
(Detach and forward above information to Road Department Riverside) .
284-230, REV. 1/74
OCT 3 01978
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