0205-261 (MECH)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
6$17746 C20 C} 1/2(
r` ;;.Signature of Contractor�r
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 &9ftVfi0o ' 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 thosys rrovisio
Date: fA•Applicant-_�—V
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 upgy .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 fobspection purpose
..
-Signature (Owner/Agent) ��°Date,q
BUILDING -PERMIT PERMIT#.
DATE ¢�f"ae VALUATION 4�COY61.o LOT W.0-261. TRACT
JOB SITE
i
ADDRESS J ,AWK MV4 VA yf AWO APN 774-302-02.13
OWNER CONTRACTOR/DESIGNER/EN INEER
X7�s+►�rZ T <r�^�. F 3NN .i� CIAi,��� .ADVA,04M AIR COA/ik'ORT CO3 i.01,
54.900AMMDAVALIVO 78650 AVE. 42,0211 I
LA, q1 NTA ;; CA 92253 BERMAJDA DUNER CA - 92201
185
1
USE OF PERMIT
VALUATION,
7P'F4.001, 3
andwrim con or. C614sunucrunt
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'p d
0 (J 61,1 .
CITYOF��UIRI
-IFIAIAAee�c..__ 7A
7i I-TC?'AAL C.iiNOTRUt;`I'109 Mli PLAW CHe?=
LL,w
Tom rxtwT .gyrus DUE Now
RECEIPT - I DATE: I BY_ �... I DATE FINALED I INSPECTOR
'7,04410D
X31.50
$0,00
$31.50
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 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.
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:
L
FPOI1 PHONE NO. : 760 775 1537
CONTRACT COPY HEATINOMOOLING ESTIMATE AND PROPOSAL
_SErARS, ROEBUCK AND CO.
DATE OF ESTVIAT� CU'irOME:i G1�Nl: r�
7su.<k r1 (JAS% e �,rl,!•<,s r
May. 219 2131712 e3:15PN PL
100 Puente Hills tviall, City of Industry
CA 91748 (800) 659-1172
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FLUE VIEW AH QH-Q4uaeY:
USE ons7riNG VENT OR C:MININEY ❑ REPLAtZ FLUEE
INSTALL NEW CHIMNEY LINER ❑ S'IZE
PYC VENT ?IPE FOR HI -E FURNACE HORZ ❑ VERT ❑
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NSTALLATrh:? WFEbV IF DIFFEREIrf
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AIR CLEANER EX3STING ❑ NEW—
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FURNACE(AIP.'HANOLER EXISTING ❑ NEW L -Z REMOVE OLD EQUIPMENT FROM SITE LEAVE ON SITE G
i CONDENSER I/NIT EXISTING LL NEW ja GRATIN LINE EXISTING C3NEW ❑
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EVAPORATOR r,0111 EXISTING C-1NEWAL CONDENSATE PUMP EXISTING ❑ NEW'❑
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LICENSE lf,_ _ -
ADGRESS
TWOS rQlljRAL'f PRiCeI~-U3ScY IPIIP�; 1L�RLCg
_',:'EAR MAINTEN♦A' N,C�E, nAGREEMENT � �,J Z � •��
• t REPAIii PLAN �r�Vri A
NPS OODE �%l A G70
A88EST09 A9ATfiMENT_
THIS UFFWATG AND PROPOSAL ASSUMES NO ASBESTOS \MLL ME DIS"IUPBED IN TNG
PGRFOWA& CF Y.ORfI IF UPON :URTNER C+6PECTI t Bl' CONT}SACTOR CP. OTNFP:,
A3B5108F 470 BE OISTURI&ED TO PERFOAU WORK, CVBTOMGR MUST ARRANGE AND
rTA1,' FOP. ABATEMENT OP ASBESTOS PRIORTO : Y.E START OR WNTPNR ON OF NCRK.IC
Cl16TOM911 FAILSTC ARRANGE FOR NECESS -Al 461325705 Al3KBN^_Ni WITMNTWATI
D BEARS MAYCANCEL TM9 PROPCTS?S UPON WRr SEN NOTICE TU CUS10L CLF.
CUSTQMG P,�= A
SEARS le NOT P&BROtWOU5 FOP. ANY EYISIEKG C40M YIWARUNB OR PRE-EXISTN6
CONOITK.INi OF ANY I)UC7VVORIC FIFRIG, ELECTSICW, ;AIPFV ES OR E1LIPMENT Nor BEING
PEFLACEC AT 71113 T17E. iF AOUITIONAL PARK IS REOUIREO, IT VrIC'- BE THE CUSTOLIER'6
rmsroT+CTeIUTY.-VJ. GIT At 099' LI'- BE OUQTED ANO 4PPP.OVED FIMR 7OTHE<
START CFADD.'11CNAL'r;0 _
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TME iNORK WILL START APPAM(IMAIELY 7L1.J/ - AND WILL BE 2UBS'TAKTIALLT
.0016PLEIM BY APPRO)GMRELY _.., THESE UIVES ARE SUdIECT M
. CHANGE n THE nve 74E ocmrRACT t4 ACCiFTEO BY -V-APS OR AT ANY OTNER T91E
BY MUTUAL WRITTEN AIAKDAGNT. I UNOERST4.ND YHAY .THI: 16 ONLY AN ESTIW'M
DATE AND 1 WILL EE i0N1Av"TED PRO4 -07141S DATE TD t;VeDLAE THL .ACTIIN.
INS?ALLMtON (1w7E
' EZLLQD OF PAYFAENTr
f❑SEARS CARD'" ❑ SEARS I,4ASTERCAP.(7' LISEARS PREMIER CARD—
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ACCOUNT o / /
ARS HOMF IMPROVEMENT ACCOUNT -(OR HIP) ?
_-r#ISCOVER CARD, ❑VISA C_lMASTERCARO GCON9EC0
10CAS.WC14 IdAMEX L7CTHEF_.„�
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AVPROVAtGODEI
EXPIRATION DATE:
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JELAYEPBILUNGDATE:_}� OZ '' ti
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NOTICE TO CAUFORNIA'RESIDENTS ONLY: IF THIS CONTRACT IS IN EXCESS OF $500, "YOU AS OWNER OR TENANT HAVE THE RIG1iT
TO RGOUIRE THE CONTRACTOR TO HAVE A PERFORMANCE• AND PAYMENT BOND OR REFUNDING CONTROL.-
aY SEAP,S. ROEDIICKANO CD Cel. lir:. 26455 WA. Uc GE AR•SR4372NT NM Cic.2237 OR 6LORS. Rep 1057 to LiC. 5843 NI Uc. 4283 AZ LIC. 079952.079951, L>;10304,
013509, 013511 UT Lir,. 22-9254011.5501.
-NOTICETO BUYER: YOU, THE BUVRL MAY CANCEL i#LLS -TRANSAC71bN AT:AKY TIME.PRIOR TO MIDTi16HT OF THE THLRD BUSINESS
>DAY:IFIFTH BUSINESS DAY IN ALASY,A, FIFTEENTH BUSINESSIDAY'LN NORTH DAKOTA IF YOU ARE AGE 55 OR OLDER] AFTER 7HE DATE
--- • -----• _-,_ _..-- _ _...._., --1 — ^19-11 1 -. — .nne4 r.. T. RL+ CV151 AUATInGI Inc Two o1n MT
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