9801-140 (PLBG)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapit✓nQi(cUmencing 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
480961 C-42 � j � 10131 99
to 6n ` Signature of Contractor``
f
OWNER -BUILDER DECLARATION r'
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 }7 I((1 Policy No. (�
IND
(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,�an� gree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall fo hwith comply with those pro Iv sions
1/Date: 0 7 �4C-,Applicant d� 0 .,_
Warning: Failure to secure Work' C m pensation 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 lawp)relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned prop (rt,' for inspection purposes I
VS%ignature (OwnedAgent) �K n� pate "..7 /
BUILDING PERMIT PERMIT#
rlfta3'1-1.8l9
DATE1,27
VALUATION ei�0:4.6'Q9 LOT
JOB SITE
ADDRESS 51-620 AVE, NIVA IHAZ APN
CONTROL#
TRACT 6771
773-121-664
OWNER CONTRACTOR / DESIGNER / ENGINEER
.1ll.C:.4't; 11 A1.i'X.4ZE IsC4.)ILrQ 8f-MUt S1:RVI[CE .
51CN20 jkVF 01AZ P.U. BOX 02
L.A. QUINTA, CA 92,53 PAU&I DESERT C 1 92'3n1 '
Ctisft)�t16-2 t CnI.,,"� 3421
USE OF PERMIT
PLUMB
SUP -W. A tBAHDt: N, SFW UR: C;OYvFR6r T
VJkLuNrICIN
E J.d Li'.r„{i-y d'J Al '�.�.d�J' 01114 6..\At Vi.Y.9. i\.�1 Q. ' r. --N . .
PLIXI flilivQ FEL _. ;(BWER 101-im-41 1-000 41.00
Al'
JAN 2 7 1398'
CITE' OF LA GDUNTA
.10
44 k"
SLfi3-"!"i71;A1,, C,"<.)k�,iC".'i_'F L1f�7_"ll�N A.Ni� P?,...A)V e:'•3-1??{."..T,':, � �'itl C►f}
1U."PAM MES $0,110
LESS IT
RECEIPT I DATE BY DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
`Y
Backs
Underground Ducts
II s & 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
POOLS - SPAS
BLOCKWALL APPROVALS
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
COMMENTS:
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
l
Final
Utility Notice (Perm)
Received From:. `
Address: 72' t � 1&1'1
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
�2 7—
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p ;1,Lk0 o
Account No.
--C1
Lot(s)
Tract
Service Address / —
&UC • 'h/A
G.A. Code
❑ Meter(s)
Cash
$
❑ Service(s)
Check
❑ Backflow(s)
Money
❑ House Lateral(s)
Order
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge
(],
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ . Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL $
Water Service
liA
Cashier )- Y. j/
CVWD-438 (11189)
/ C"L,
/,)(Remarks:
/opy to:(C
Cash
�3
Check
; 71
Money
Order
TOTAL $
Water Service
liA
Cashier )- Y. j/
CVWD-438 (11189)
;R +ERVi ES
P.O. Box 192
PALM DESERT, CA 92261
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AM UNME OEM
N2 - 8357
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s4o-G�V3
A O RFR
CUSTOMERS ORDER NO.
I PHONE
MECH
HELPER
STARTING DATE
BILLTO �
TOTAL AMOUNT
1117 ,,
$
ORDER TAKEN BY,
ADDRESS
❑ DAY WORK
[-] CONTRACT
EXTRA
cl
C
JOB NAME AND LIJUATION
/
JOB PHONE
ION OI
PLEASE PAY FROM THIS INVOICE
tt� No one home Total amount due El Tial billing to
r above work: or b mailed after
1 hereby acknowledge the satisfactory completion completion
of the above described work. of work
TOTAL MATERIALS
TOTALLASOR
NO STAT ENT WILL BE MAILED
TAX
AI
DAT COL ED WOR RDERED BY
TOTAL AMOUNT
1117 ,,
$
tt� No one home Total amount due El Tial billing to
r above work: or b mailed after
1 hereby acknowledge the satisfactory completion completion
of the above described work. of work