9605-069 (PLBG)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 .
10/31197
ate f %� Signature of Contractor"OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1,, 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•Issu' M (workers' compensation insurance carrie17 r &/`policy no. are:
Carrier 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,rand 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.
ate: �� / I1� Applicant—
V,
Warning: Failure to secure Workers! Compensation coverage is unlawful and
shall subject an employer to criminalipenalties 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
constrdction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
:%
Signature (Owner/Agent)',�""�`"���PVt1AA,""'"""'Date
BUILDING PERMIT
PERMIT#.;.:,`•
�wy
CONTROL
DATE IB r y VALUATION 2,"0-00 LOT
F+i!'.; TRACT
32
JOB SITE54 S A IDA VF��..AiE- 10
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CAf'.cl .f �,.
ECCNo SnVER SERVICE
54.085 AWt4 i& VALLE J 0.•
84033 CABA"YMN 1i).
LAQi)!Nl�, •C,A 9'12: �
PAI,'tifl �)ES1:SZ:i l"� !r27�i
CAL* M2
USE OF PERMIT
PLUMBING
C(AST
C;3F CONSTRUCTION
N
t,afif�tl.i3i6
PERAIJIT14M, SUMMARY
f?i,C)iVfi3'INCiiFfi! W-':i31AlF?R .101.000-0)-:000
-..,.,_ VOTOTAL twt`}NX17RUCHON AND PLAN C'k[ECK
S30.00
7
LESS PRE-PA1t3 `f EES
$0.00
lf'Ai: i�%1 Mll'
FECS; fi9liE NOW
!630.00
fr9q Y 1
1996. .
RECEIPT
DATEBY
F.
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PI . 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 4vEncapsulation
Gas Piping
Gas Test "
App 'ances.
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVAL S
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
Ut. Notice (Perm)
COMMENTS:
Received From: /3
Address: I L(U iu 'r -U 5- f ! rl l ? L ��- Ing
Account No. I-2- L t(s)
Service Address
O Meter(s)
❑ Service(s)
❑ Backflow(s)
O House Lateral(s)
O Detector Check (a)
O Meter Surcharge
anitation Capacity Charge S
O W.S.B.F.C.
❑ Temporary Construction Meter
O ' Turn on Charge
❑ Uncollected Account- Name
❑ Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
O Bond Payment - A.D. - Bond
Assmt.
O Customer Deposit
❑ Otter
Remarks:
❑Copy to:
Cash /
Check
Money 1 %y
Order
TOTAL $ �� �.
ECONO SEWER SERVICES
P.O. Boz 192
PALM DESERT, CALIFORNIA 92261
000 RaaMR
47126
PHONE 32ts-//60 346-2793
TOTAL MATERIALS
O
A
CUSTOMER'S ORDER NO.
PHONE
MECH
HELPER
STARTING D
BILL TO _
NO STATEMENT WILL BE MAILED
-
ORDER TAKEN BY
ADDRESS
WORK ORDERED BY
.
TOTALAMOUNT
DAY WORK
CONTRACT
EXTRA
CITY
JOB NAME AND LOCATION
JOB PHONE
ION OF WORK:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
1%% PER MONTH CHARGE AFTER 30 DAYS
•
TOTAL MATERIALS
TOTALLABOR
PIEASE PAY FROM THIS INVOICE
NO STATEMENT WILL BE MAILED
TAX
DATE COMPLETED
WORK ORDERED BY
.
TOTALAMOUNT
$
No one home Total amount due #"ff Total billing to
Signature for above work: or be mailed after
rSig to nrEes inc completion
0 I hereby knowledge the satisfactory completion of work
Smton Man 01471. 'ot the above described work
M