9604-129 (PLBG)LICENSED CONTRACTOR DECLARATION
U) 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
N W Professionals Code, and my License is in full force and effect.
p D M License # Lic. Class Exp. Date
I O `n �i57.5 i Cab Citi �/ . x1311 a .
r1
Z � Date Signature of Contracto
CD Q �.
OWNER -BUILDER DECLARATION r v v
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
1--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).
( ) I am exempt under Section B&P.C. for this reason
L
N Date Signature of Owner
ON
O)
Q WORKER'S COMPENSATION DECLARATION
CL
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
HQ () 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
O J Q performance of the work for which this permit is issued.
m Q U ( ) 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
L Z permit is�•r'ssued'NjyMworkers' compensation insurance carrierf&ti policy no. are:
Cartier Policy No.
ob:5
r` C)
J(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 Californiarand agree that if. I should become
ybject to the workers' compensatd1pols-pe
rovisions of Section 3700 of the Labor
3 ode, sh .1 fort with comply with' provisionsr ,r
Date. 1 pplicanl�r` ,��.v�i-•"/
.� ,
Warning: Failure to secure Workers✓C, mpensation 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 applicator 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 FGOat 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
cctistruction, and hereby authorize representatives ooPthis City to enter upon
�= the above-mentioned property. -for inspection purposes.
ti Signature {Owner/Ager) �� Date
BUILDING PERMIT
DATE 4/,2M,96 VALUATION . - S1e80%(") LOT
JOB SITE
ADDRESS 51-•7.15 A'6+'VNIDA "VALi.FU0
OWNER
SUE 1JUNr
51.735 A EN10A VALL8J0
LA QUINVA CA t2253
USE OF PERMIT
PLUMBINO
S}3WU t C01NNEC1 781IP11C ABANDOK
PERMIT # CONTROL #
'
3203
TRACT
APN
CONTRACTOR/DESIGNER/ENGINEER
DMEITi::11.t2EE) P.1,U141I:ING
P.O. 5178
PAT:M SPUNGS CA 92261
Q
C 14 322-3:173 CBIX :2229
F.ST1N;E.XfF,® COST OF CONSTkt1fS:,°T ON
PERMITYC9 SUMMARY
PLUMBING :E'FF, -- .'IF:WER. 101-000-419-000 V0.0
SUB -TOTAL CONS'TRUt:'7T[:N AND FLAN CHECK
LESS RPM -.PAID FEES
4:nTA1, PERMr1.' FE1,P% VtW ! OW
I
. APR 2 X3.1996
,�
RECEIPT hATE� BY DATE FINALED INSPECTOR
.11900.00
$30.00
$0.00
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
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 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
Ap iances
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:
-----; CHCS(% 2'Sf'2 Q Lots)_ Tractt�!^���'
Account No. 2 -�
.': Service Address S�- 7.3.S` �� �F-1 n G.A. Code
�.., ❑ Meter(s) $
❑ Service(s)
.;� -D Backflow(s)
❑ House Laterals)
❑ DetectorCheck(s)
❑ Meter Surcharge
``po'anitation Capacity Charge
❑ W.S.B.F.C. -
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account- Name
( ❑ Inspection Fee - Tract -
Fee -
❑ Plan n Check Fees Water l Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
F ❑,Other- .I.
F _
^7T \ TOTAL $ �
S
t Remarks: T /V0 <�-A I I-AC� 1
� �i
pCopy to: C—n')
Water service
Cash
Check 672 r
Money Cashier
Order'D-438(11189)
r
. . _ Cashier. •
r VWD-438 (j,
C. 7S b3p ... ....
SUSAN HUNT 678
NANCY A. ARRACHE
1538 BELLEFONTAINE CAM Cash Management ACCOunt"
RIVERSIDE, CA 92 6
///i / C 25-80
PAY m Tuc _ // �.O / i.-'•�--i� 19 .� aan '
SANCO
PUMPING SERVICE 2502.Morongo Trail
Palm Springs, CA 92264
(619).327-8859
1232
SO TO
SALESMAN
TERMSF.O.0
SH'ITPED TO
DATE
14
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s4rREET,,; NO./-5TATF
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STREET" NO.
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STATE
ZIP
CITY STATE IP
CUSTOMER ORDER
SALESMAN
TERMSF.O.0
DATE
14
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