9606-028 (PLBG)LICENSED CONTRACTOR DECLARATION
U) e I hereby affirm under penalty of perjury that I am licensed under provisions of
H• Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C\1 W ,Professionals Code, and my License is in full force and effect.
O Z) (D License # Lic. Class Exp. Date
U7
W ^ i3 XB3 l� ref) t.ltt
f�
Z N Date Signature of Contractor
T
O�
CD U rn OWNER -BUILDER DECLARATION
LLl I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ d 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).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C'') O I am exempt under Section , B&P.C. for this reason -
LO
N Date Signature of Owner
ON
rn '
CL Q WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LO O () 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.
00
Q U ( I have and will maintain workers' compensation insurance, as required by
O(J Q Section_ 3700 of the Labor Code, for the performance of the work for which this
4 Z permit is<jssued tAyj1workers' compensation insurance car,e� ipolcy no. are:
Carrier Policy No.
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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 California, and agree that if I should become
1 subject to the workers' compensation provisions of Section 3700 of the Labor
e�•i7 Code, I shall forthwith comply with those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful.and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions' and restrictions set forth on his
application. .
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
�\ any permit issued as a result of this applicaton agrees to, & shall; indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all -City, and State laws relating to the building
construction, and hereby arize"r�presentatives�of this City to enter upon
the above-mentioned propertyfor inspection purposes.
Signature (Owner/Agent)Date
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BUILDING PERMIT PERMIT # °°NTR°`#
3459
DATE {�lG VALUATION.}•�i�4� LOT , TRACT
JOB SITE
ADDRESS .11-720 Ai"ENIDA VAU,100.
APN .
'774-123-012
OWNER
CONTRACTOR/DESIGNER/ENGINEER X
I7 X 1 f'A,L 111ON-1, V LOAN A11,10 c 0ftP
NW1I.AAE11O." to►f;`.
5X120.AL [,N1 X1v VAi.t,,E O
5141i EiSENHOWJs:K l)it,
1,AQUKI- ("A, :7153
LAQl1TN1•'A JIe-A 92253
s'R•1'A.(u iL t 2526
USE OF PERMIT
�v'13.i�7� [Lt��!'f` (•11�L6JIJl. �1 i' A)�iL/l4et�} d. 7
•
r
isu'SiIM.t.A'C7+ D OUST OF C 001 ,,$XRtFCl:1ON
1.000.00
PERMIT FEC81-IMMARY
OUIl 1N•NGrEE. »- SEW'0t •101000-41910(> $30.00
SU -TC rAL CO S$'RUC'iTON AND PLA14 C14ECK
� tiJ.G4
LESS RRE-PAID REFS
50.00
TOTAL PERMIT 1� : '4 DUE NOW
$30,09
• i
RIICEI }
DATES �,
BY F r
DATE FIN LED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
y 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 Wali 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
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
Az
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)
•'
COACHELLA VALLEY WATER DISTRICT
..
CASH RECEIPT DETAIL
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I Received From: ' "\ �.�. W� `- t
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Address: Y
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Date.
(' AccountNo. 4b 1 Y
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t s) Tract
Service Address p
C� e. G.A. Code
❑Meter(s)
$
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
0,19'anitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Constructlon Meter
❑ Turn on Charge
'
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -T.
❑ Bond Payment - A.O. - Bond
Asamt.
❑ Customer Deposit
O Other
TOTAL
$ CJc�%S U
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Remarks: l VAN 1 1 v1 Iray�
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❑ Copy to:
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Cash
Check
Money'
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Water Service
Or
Cashier
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CVWn-d..V 1111ao1
.. ....... .. .
SANC2SERVICE' PUMPING SE
,I . I . .
. 2502 Morongo Trail
Pailm Springs, CA 92264
(619)327-8859
N! 10259
SOLD TO
SHIPPED TO
S*FiEdt NO. STATE
STREET NO.
Y STATE Z;p
CITY
CITY STATE ZIP
ca,
PAYMENT DUE. UPON, RECEIPT-