0311-078 (PLBG)LICENSED CONTRACTOR DECLARATION
hereb}aaffirm 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
/- 658803 1B 11430, tc
Date �. ,c /3-67Signature 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
( ) 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). t
( ) 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 f9'1'AT1C ItCINT� Policy No. 1342964-02
(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 provisions.
Date: ♦s - 1n 7 Applicant / -„_�O
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 fo'r 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.
Signature (Owner/Agent),,- Date./
BUILDING PERMIT PERMIti; -
DATE �� *� VALUATION LOT TRACT
20 1n;K14 U2
JOB SITE
ADDRESS $ti: CAwarE�'.
APN
OWNER
i
CONTRACTOR / DESIGNER / ENGINEER
33.iY.S .vu
CU2+3',��'MUC-170N CO,DTC.
51-300 CAUS' ' T'TrWKYA .
80.655 XkNUE 43
1:.A.QUERT'A CA 92253
D.010 Gly 92201
060)341.9755 C DL4 5.91
USE OF PERMIT
PLOWING
ltii.,fLNiJCg3�IftV44°N7' O�"1'f?;A4PQFi.A.RY S_R3A�'1C ��^i�'L�;?��fSf�`�kR Ct71;t1d�C'I'. •.
VALUATION 3,DAD,901.101
EFs', iATM COST OF C't?Ni5M'EvMON
�,��►:44iD
PILUNlHS'l O "ASE -- Q1 WW1 101.000-/9Y19.000
NOV.'
CITY;OF
1`�1tilRtlfA
FINANCE pEc►T, .
SUB -TOTAL e"01 1R13C'3IO N' AM PLAN, WE=
$30.00
IMS3 PRE-PAIDIWKS
$0.00
7►`OTA1.PEW. - rli IT,1:'13'. DIST.: i6W
$30.00
V
RECEIPT
DATEt
BYE
D E FIN ED
INSPECT
a
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
FiW,I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Mste 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 s=
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:
Nov 10 03 11:18a William Tribble 7603429825 p.2
�tA Of A`F
*� County of Rivf�rside
* HEALTH SERVICES AGENCY
q r s t 8q0 DEPARTMENT OF ENVIRONMENTAL HEALTH
DATE: September 15, 2000
TO: William Tribble — Owner
FROM: Don Park, Riverside County Dept. of Env. Health
RE: Wording of Required attachment for deed on parcel:
APN: 769-114-005-5 (80-655 Ave. 43, La Quinta)
A temporary septic system has been installed at this site because the public sewer is to be available
within 9 months or less (according to the City of La Quinta and C.V.W.D.). Coachella Valley Water
District says the connection fees have been paid and this Department is requiring a "dry line" to the
street. When the connection to the sewer is made, the temporary system will have to be properly
abandoned (for which there will be some cost). If the temporary system fails prior to availability of
sewer, the system will have to be pumped or additional pit(s) installed.
Nov -10 03 11:18a
r
William Tribble 7603429825 p.l
f
P.O. Box 1504 -
78-495 CALL1: TAMPICO
LA QUINTA, CALIFORNIA 92253
September 13, 2000
To: Whom it may, concern
(7 60) 777-7000
(TDD) (760) 777-1227
Re: Assessment District 2000-1, Phase VI Improvements -Areas A, B, C & D
The Property Owner: ��=� APN 7G9 ' 1
14- nos
is located within the City's current sewer assessment district. The City anticipates construction of
sewer facilities within the referenced project limits beginni:ig in mid to late October 2000 and
expected to be completed in late May 2001. If you have any questions regarding the project please
don't hesitate to contact me immediately at 777-7045.
Sincerely,
M. Freeland
Senior Engineer
c: Tom Berg, B&A
Project File 9849A,B,C&D
T:IPIVDEP MRO/ECTS\98Prjcts19819PhVNetkrs\GnriGSvrMmo.%pd
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