9803-001 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch9pfer 9' (cmmencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect. T
License # Lic. Class Exp. Date
1W961 C -tit i0/3Ilyre
Date 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:
( ) 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).
(yy)' I, as owner of the property, am exclusively contracting with licensed
Eontractors to construct the project (Sec. 7044, Business & Professionals
Code).
0 1 am exempt under Section , B&P.C. for this reason
✓Date TV Signature of Owner ///i,
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 ' 1 Policy No.
-rim,
M.I6-9144 lU6w09'
(This section need not be completed if the permit valuation is for $100.00 or less).
( I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provi�$ions.. /
t,/Date: 2 Applicant—
Warning:
pplicant 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.
r f r
Si nature (Owner/Agent) ent ���'r - '"�f• f "��':,IDate 2'�
9 ( 9 ).
BUILDING PERMIT PERMIT CONTROL#
1741)34#3!
DATE Z�!) VALUATIONLOT TRACT
6904 Q0
JOB SITE ADDRESS U-Rilfg5AVEj� OA VCU.Y�Y�ls 0 APN 774_30AIN
OWNER CONTRACTOR/DESIGNER/ENGINEER
54865 AVENIDA VALIA.,'JC) p.0, box 02
LA QUINTA EVA 92253 PAQVI D skicr CA 92261
(760)346-2793 CRIA 342
USE OF PERMIT
SUPTIC AMM)01.4, SEWER CONNECT
1,4000) I'S
'iIANIA•T it,D'VO3T 091 ��aV�7 lA i\ifs a K0.3ly i�rltiit,�ie�
F,Ith IT PEW 8Uia MARY
PLOIbi9#INO Ffl�', -- SEWER, 101 -WO -419-000 ` fti3u.tut
'
PAID
z '
MAR 2 1998
CITY OF LA NTA
' t
f�
J �t
tJI3-tVtIti.,C0-NT'R (JOV, 0 N', A. N 0 1 " 1-1 A N ( 7 I U t CX pnoo
LESS PRETMD FEE'S $000.
RECEIPT DATE BY/ DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
yet 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
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
&77
Encapsulation
Gas Piping
Gas Test
Appf . ces
/�t%✓ � �
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles '.
G.F.I.
Smoke Detectors
Temp. Use of Power
c
C
Final
Utility Notice (Perm)
Final
COMMENTS:
Phone azo-: ou _ /ORDERCj
C
C�VSTOM R'S ORDER NO.
PHONE
-
M HA C
HELPER -
STARTING DATE
NO STATE ENT WILL BE MAILED
TAX
DATE COMPL TED
WOR DERED BY
TOTALAMOUNT
$
BILL TO
ORDER TAKEN BY
C
'
ADDRESS
El DAY WORK
❑ CONTRACT
CIT
❑ EXTRA
JOB NAME A LOCATION
'
O
JOB PHONE
_ _•....... v v `~ PLEASE -PAY FROM THIS INVOICE
t
• '
TOTAL MATERIALS
-
TOTALLABOR
NO STATE ENT WILL BE MAILED
TAX
• '
TOTAL MATERIALS
-
TOTALLABOR
NO STATE ENT WILL BE MAILED
TAX
DATE COMPL TED
WOR DERED BY
TOTALAMOUNT
$
❑ No one homeTotal amount due ❑ Tot f billing_to
Signature above work: or be ailed after
As I hereby acknowledge the satisfactory completion completion • of Work
of the above described work
jL
t'
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
�O 7/ Z.'
Date' 3
Received From: �� (�' At V I
AJC PJ p D/� �,/.4 C �,� O
LA (Sl U!
-
l
Address'
,
Lot(s) (, Btu
1 I Tract SF �riA
P tMs
G L I7 -A
{'
Account No.
Seryice Address /= /� N ILEA `ANLd
G.A. Code
'
0 Meter(s)
'
❑ Service(s)
y
-
❑ Backflow(s) _
•
❑ House Lateral(s)
❑ DetectorCheck(s)
f
❑ Meter Surcharge
natation Capacity Charge ell
Qg
, 27-5 5
!
❑ W.S.B.F.C.
❑ Temporary Construction Meter -
❑ Turn on Charge
❑ Uncollected Account - Name
{t
f
❑ Inspection Fee - Tract -'
` (
Fee -
f
❑ Plan Check Fees Water I Sewer -
,
Tract -
j
❑ Bond Payment - A.D. - Bond
i
Assmt.
K
❑ Customer Deposit
❑ Other
p
..
t
TOTAL
Remarks:
to: 1', J U D5' P>7
. i
. , opy
Cash
Water Service
C
�
Check Q !fi %
Money
,:
Cashler
Order
C61)438(11189)