0107-113 (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
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).
( ) 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:
�() 1 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 Policy No.
�.,rx�llt3>kz
(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,
t 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 thou, provisions. .41
,pate: * r 1 r_h „�., 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. AnyKperliiit 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)Date
Orr r
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS ,O y PAL MA DRO
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Jq'I��t;.aQ'�i:7(r"��A!i'�ptI99.�Y,`XIppF���;AA.CyL^yE,
.k�DV'1/��tpT���:yy2���; 3. AIR CONTROL
i' 99,50 .� A k"d:i�4i6F.!:t? i..,',:.1+
ryryC"*�;�1.Iv(.t�l'�F�:f
766,5 N dTY.i'r. 461 4 1 1
TA Quivax CA 922S3
DERM17DA, DURRS _A 92201
'760)275�8785 ClUA 6407
USEOF PERMIT
�
PJ,?PI.SCC;RXISJ`WOAIC UNI`1, AND iAU. (.10 3YE1Z.MfldM9UDA)
VALUATION is
X5111K'1t8 COST Ole Ve•47.6vtJ'JLd0.W+C.8.G011
.���✓��1.7..V7f
Y?mo m r plim ATIM ARY
MW?Pll,NICAL FE 101-000-421-000
I�
/� iii Pj
lips ',;� J( ,
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JUL 12 2.001 r
Cf•f� 011 i'Uli'?r1
f
C' £ li I��Iai Z31a TCC ,
$39.50
S0.00
,MTAL PFJMT1 05 TAM TgCOW
S39M
RECEIPT
DATE , } i
BY i
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
Steel
POOLS - SPAS
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:
FROPI : SEARS-HVAC-PUBENI-G.0ALDIUIEZ-- PHONE NO. : 760 775 1637 Jun. 29 2001 03:03PPI PL
HEATINCI)COOUNG ESTIMATE AND PROPOSAL No.
CONTRACT COPY SEARS, ROEBUCK AND CO.-
DATED EN't
L• `/V ORP�S A.�� , 1` K STATE- � G i7p CODE PHONE
/j r{i/ Cv L I
--.
HONEPMORE•!E
CUB OL¢R'S NAME 0ME, PHONE J•s�+r�
_
TDORESS CrTV STATE_ ZIP CODE
Drr�c Cs� `�L�5
SU -.E HP CODE
!NST�DDRESS IF GFFEACUT CRY
-
B71,1'S y
COOLING —4-A SEER 1Q-- o _, H nNG Q AFUE R
—
EQUtPMFNT MODEL s'S= FJaJE VENT AN0MIMNEYy
ZIRNACEIAIR'RAI�FR Ics O�� ^ TSTAT EXISTDYG,® NEW a _.-,_ 1jSE EXtSTD4G VENT OR CHIMNEY ❑ REPLACc FLUE Ci
CONDENSER uN1T L.— COOLER t 74S'TALL NEW CHIMNEY UNER ❑ SIZE——
PACKAGE UNIT ABoaER t _ PVC VENT PIPE FOR HI -E FURNACE NORZ L� VERT❑
EVAPORATOR COIL 9rirrri� ' OTHER R CONIMMION AIR ❑ EV STu4G ❑ MODIFY ❑
.. ••• _. 1 PIPE INSTALLATION ❑ 2 PIPE INSTALLATION ❑
RETuRm A1R ❑ EXtsTIN3 ❑ MODIFY O
ECUIPIt1ENT SPECIFICATIONS:
FURNACE/At UdAN8k,ER EXISTING ❑ NEW FS DRAIN UNE man NG ❑ NEW ❑
OONOEMER UNIT EXISTING ❑ NEWO CONDENSATEPUMP DUSTING❑ NEW ❑
'VAPORATOR COIL. DUSTING U NEW 0 SLAB DUsnNG ❑ NEW G SIZE
LINE SET @XISTmEl NEW ❑ OTHER—— E7USRNCi ❑ NEW ❑
REMOVE OLD EQUIPMENT FROM SITE PJ LEAVE ON SITE ❑
quer ays'u IL-
FI1T`1 L
USE EXISTING SYSTEM0 ADDTO EXIVIN3 ❑
CONNECTTO I:XIS'1D1d PANEL,0 INSTALL NEW QISCONINECT GJ
lNSTAWNG NEW SY81"EM SEE SPECIAL INSTRUCTIONS
INSTALL NEW ❑ AMP SERVICE ❑ SAME LOCATION ❑ NEW❑ ,
REQi3TERS USE EXISTING Ir NEW ❑
ADDITIONAL WORK ...
HUMiDIFIERB ExIsrime0 NEW t, AIR CLEANER E70SRNG❑ NEW DUOTCLEAW40 YES❑ NOD
07457,3
CONTRACTOR • UCENSE0
ADDRESS _
TH NTRACT PRM* MCLUD
YEAR PAAINTENANC6 AGREEMENTC) _
REPAIR PLAN L7
ASBEWCSABATED1ENT
_YEAR
NPS CODE
TMS eaTIMIMS AM PROPOWkL ABEJs G NO AMMM WU BE D19119WEV W
THE PSRI OF VVK IF UPON 141RTHER WSPECTION BY OONTRACIOIT
AG NESS: GEARS R1 N01 KSP046(BI.E FOR ANY emsTM CODE rid,A-
OR OTHM& A EUM 0149 TO BE OILM >BED TO PER ORIA WORK. W9TOLOR BUST
iCUSTOMER
TX%IBQR'RE,-4MIOCC&RWNS OFANYOVGt»OWP(PGlr EUB.7RICALSUPP.MOt
ARRAIIGiEANDc FnRAB10HBYTOPAMMOSPFWRttI1NB5TARTORWN11NL'-
NOT HHNO RU AGM AT THIS TIME IF Am/TIOPUL YIORIf 1S REIC VW. R ISRU
KION OF WMM IF 0AMPlKR LALG TOARRAM E FOR R6LT>.74ARY ASSEGTOB AAATE-
ISQVIPMENT
BE THE C-96MITERTi RFF?ONSMI, I AOORiONAL CRAROB, UISL BE, WCTVD AND
IEAI 1MI . YHTRY go DAYS. SCAR. uAY CANCEL THI3 IW11084L UPON 17RITTBN
P TRE START OF ADOIRONAL Y40M MA ArFAM PLUI WAS SEEM
MDRCETOCL161O®t
MAPPROVE!/
REC-al .
TRH WORK WILL START APPROXWATEIY AA0 T/6L BE SIBS711101T " OOIDLETW BT a ptOWU OTHATTWIl ISONLY AN 6STIME DATEMD I MRLBE
APMOAMAT" --....__-- TtIPSE D9T1i5 ARE 6URECT TO CHANGE AT TIE TW& THE CONTRACT 16 LONVJ=VD PRIOR '10 TWIS DATE TO SCHEDLAE TNG ACTUAL
ACCEPTED BY SEARS OR AT Aur OYHLTI TSAS BY MUTUAL WRIrrm ASRSM10M UlWA1,ARON DATE:.
C.ONrMACrCTT PRICE' (DaOWT1
pwwco
0>+�1
V 75
✓
AT�Fi�I��WRL-
❑ SEAR9'CA.RD ❑ CASH Ii 150K ❑ AMEX SUIBMITTEDBY 0".."'g. &Z J'/!w'.
. 6 SEARS HOME IMPROVEMENTACCOUNI'(ORHIPJ!!r �P�—A�__—tr9.
[lO1SC CARD v1AACEXP.DATE (ADDRWNALPOE'TW8PROPOSAL.ARE/ST,A,TE DNR- SES10E.)
SA77SFi4C770NGUARAA"Lw DORYO!!' MONEYBACK" Lf! L
(OUSTOmms CWATIRE) (DATE OF '
i.,Wv w re Vtw mars r k -v-, same Ina*mw aPaw4 o—h--W.0-mae"oam PPWh-b-bjd 4MIww'. C?b NA
.. cAWe pu,dvw u'dd to m t rawm rt 1ft SATr. W&d Sank men 1 awtum IRta is a w-tv idNael i V* erTa!� dry Daeon. h alwltl;alc_ Rim IhA Imfu d tA/ MtaM+R
NOTICE TO CALFORNiA RESIDENTS 011M. IF THIS CONTRACT IS IN EXCESS OF $500, -YOU AS OWNER OR TENANT HAVE' HE RIGHT
TO REQUIRE THE CONTRACTOR TO HAVE A PERFORNMCE AND PAYMENT BOND OR REFUNDING CONTROL"
By MWIS, ROEBUCK AND CO. CBL Lic. 25455 WA. Lio 8&ARSR,1372NT PUII Lk. 2231 OR SUM Reg. 1051 NV Lit, 5543 HI Lit. 4285 A2 Lir- 079952.079951, 0803C4,
019509, 013511 UT Lir 22-23640&5501.
NOTNE'TO BUYER: YOU, THE BUYER, MAY CANCEL THS TRANSALTIGN'AT, ANTTU KE MDR TO MIDNIGHT OF THE THIRD BUSINESS
DAY [FIFTH BUSINESS DAY IN ALASKA, RlFTffNTTI IRWRESS DAY BI NORTH DAKOTA IF YOU ARE AGE 65 OR OLDERJ AFTER THE DATE
OF THIS TRANSACTION. SEE THAI CGTAMED NOTICE OF CANCEUMON FORM FOR AN EXPLANATION OF THIS RIGHT.