0303-263 (PLBG)LICENSED CONTRACTOR DECLARATION
Thereby 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# �IN/�1 Liic. Class Exp. Date
511,700 C36.. �iFl Vf lr1
Date12— Signature of Contractor /r-F•.� – .._..
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
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 F:} EMPT Policy No.
(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.
Date: rM �' Applicant ,000
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 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.
Signature (Owner/Agent) .ijl s'��'"4 bate 3/e
BUILDING PERMIT PERMIT#
DATE VALUATION - LOT _ 0`'14 TRACT
JOB SITE q �q� +�� ��g•pry�Aq�
ADDRESS a4.%"'aJ� AV�+�1�A,4A['3Vr;&LL eiC
APN
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
CECIL T. HART f. -.t1 l
EkEllm'S PLUMMO CO,
53x345 Ailr`�i�1DAVAL1.A?J®
2 I TAVALAVE ...
LA QiiNTA CA 92253
PALM EYMM ' CA 922M
(760)30-7586 CLO 2052
USE OF PERMIT
7 L,Re PO .sCOTCHOAaAD t. TNI)ERtGRk?UVID OAS JAMEJ W V V BLACK
IRON GAR PIPIN0,
VALUATION R,3fie,Otl U
ESWAAMW COS? OF c(MYROC,110N
IIMA).it0
P ERW.r FUSUM ARY
.PVU AJBfNGFez 101.00"19-000 WIN
C�
MAR • 2. 5 2003 �� I
CITY OF LA f�Ulf�lb�--J .
FINANCE DEPT
SI i- "AL C'OM71?LA'a'�',(014 AMID P1AUbItI ,`�
� 1 8.00
MIS PRE41AID FE M-
$aoo
TMAX, FERMT FEES DIS& NOW
RECEIPT
DATE i
BY " '`id---- --
DATE FINALEI�
I 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
Finat
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��
Appliances
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:
CITY OF 1_A Of I-INTA
MAR 2 4 REC'D
-0 Ferreasll Bu°L®"�
g �P
City of LaQuinta Building & Safety
P.O. Box 1504
LaQuinta, California 92253
Attention: Ed Randall
Dear Sir:
Per our telephone conversation on 3/14/03, I wanted to write this letter in the interest of safety regarding
the property located in the City of LaQuinta at 53-345 Avenida Vallejo. A Mr. Cecil Hartman resides at .
this location.
Mr. Hartman called for an LP gas delivery of propane on 3/12/03. He was scheduled for that delivery on
3/14/03. Before being dispatched to the residence, my service technician, Conrad Nava informed me that
Mr. Hartman had an unsafe and illegal piping system in place for LP gas. Conrad stated to me that the
piping being used was PVC piping. I took this district over in January 2003. Apparently we had made
deliveries in the past to Mr. Hartman, but when the unsafe condition was brought to my attention, I denied
Mr. Hartman future gas service from my company until the City of LaQuinta green tagged his gas system
and the piping was brought up to legal specifications. No gas delivery was made.
At present, Ferrellgas will make no propane gas deliveries to 53-345 Avenida Vallejo, LaQuinta, California
until the above mentioned qualifications are met. Although we appreciate that Mr. Hartman has been a
loyal customer to Ferrellgas in the past, I feel that the safety of him, his family, his neighbors, and my
employees is of greater value at this time.
Sincerely,
Mike Saucier
District Manager
CC: Customer file
Mr. Cecil Hartman
Randy Smith (Operations Mgr.)