9801-015 (PLBG)LICENSED CONTRACTOR DECLARATION
I:- reby 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
' fessionals Code, and my License is in full force and effect.
License # Lic. Class J Exp. Date
t0% C'42 ;' , 10f.11 499
•..t4Date Signature of• Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm under penalty of perjury that I am exempt from the ontractor's
License Law for the following reason: . t
( ) 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
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:
Camey Policy No.
BUILDINGPERMIT PERMIT# CDNTROL#
DATE { VALUATION LOT "� TRACT 65014
1 r�� fG�'GiAiH S],50df.1)1i -
.IoF-SITE '" APN
51-825 AVWIDA VALLiFJO
OWNER HN gy�pp,,
_51825 AVENIDA. VALLEJO
LA Q[TINT.A . CA 92253
USE OF PERMIT
.WW R. CONNECT, SEPTIC ABANDON
VALUATION
CONTRACTOR / DESIGNER / ENGINEER
•ECONO SEWER, SERVICE
P.O. W -W 192
PAL1%4 DESERT CA 92261
f760)346-2793 CBL* 342
1,500,00 LS
STA;rE:P= GMfr98-0WM%9 .. CSTi1 IMED COST OF CO-NS-!'.RUCY10N
(This section need not be completed if the permit valuation is for $100.00 or less). PERMIT EEE'SUM MARY
(
)-1 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 P1 L1M.ATN(3 FEE " SMR 101-Q00-419-000 ISMS")
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: A r"APPlicant f/°...�'e �t � �, ✓ . --
v` /
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall sub'jec't an employer to criminal peHalties 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. Bui)ding 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 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
thhe`above-mentioned property ffo'J� inspection purposes. RECEIPT
Signature (Owner/Agent) �A �"1 Date I ��
V
JAN -® 7 1998
1
C1_rY OF T
1.
f .+
SUB-'IWAL CONSTRUf'°d'ION AND PLAN CHECK $30.00
LESS PRE -PAID FEES $0,00
TOTAL D''Edi11lIT FEES S DUE (VAU' $30.00.
e
DATE BY DATE FINALED INSPECTOR
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 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 0 0
Pool Cover
Sewer Connection 4V
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)
Received
Address:
Account
Service f
❑ Meter(s)
❑ Service(s)
❑ . Backflow(s)
❑ House Lateral(s)
.❑ Detector Check(s)
0 Meter Surcharge
anitation Capacity Charge �S
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Uncollected Account -Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer =
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL
Remarks:
a
{, ❑Copy to:
Cash Water Service
EF Check ..4•
Money Cashier
f Order CVWD-438(11189)
. ECONO SEWER SERV„ �
P.O. Box 192zti.w ,
-.PALM-DESERT, CA 92261. N2 821�
rnone Jco-i 10V
3HQ'G/ �J
DATE OF
ORDER
TOTALLABOR
NO STATEME T WILL BE MAILED
TAX
CUSTOMER'S ORDER NO.
PHONE
-
MEG IC
HELPER
5TA TING DATE
BILL TO,
ORDER TAKEN BY
ADDRESS
r
❑ PAY WORK
❑ CONTRACT
clTv
n
�
..
❑ EXTRA
JOB NAME AND LOCATION
-
JOB PHONE -
PLEASE PAY FROM THIS INVOICE
r
1100,
t ,
-• _
TOTAL MATERIALS
TOTALLABOR
NO STATEME T WILL BE MAILED
TAX
DAT COMPLETED . VIORKlaBDERED BY
'
TOTALAMOUNT
$
LJ No one home��otal amount due E]Total billing to
Signature for above work. or be mailed after,
completion
•� I hereby acknowledge the satisfactory completion of work
of the above described work