9906-181 (PLBG)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
7 Chars 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
<73088 C36 0-IM/20f
4Date Signature of Contractorw �L'"
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.
(1tj 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.
f MID -C E'' t'C1lLY RNSTA A009227045
(This�section need not be completed if the permit valuation is for $100.00 or less).
() I certitythat 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 FOO of the Labor
C,Ode, I shalj�rthwith comply with,those provisions..f
Date: 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. r
'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] have read this application and state that the above information is
correct. 1,9*6ree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
th7ea°bove-mentioned property forinspectionpure ses.
V.Signature (Owner/Agent) �1=" � � Date " /, 2
BUILDING PERMIT PERMIT
"110-181 .
DATE ft/23/2"VALUATION �i,.�oi)- LOT TRACT
,
JOB SITE
ADDRESS 5a-675AVENIXDA USA"
APN
773-114-010
OWNER
CONTRACTOR / DESIGNER / ENGINEER
IiXN tY CARTEtt
VAI.I,kY FIT UM8ING
Ir) BOX 430
4,0780 CL UVIDN
LA QUINI'A CA 92153
INDIO (2A 92201
(760)317-1679 C1311#1 IUI
USE OF PERMIT
PLUMBING
SEPTIC A.l3tiNi1 N, SEWFA C0WrE(7T
VALUATION I,friiii,t3t) I's
PERMIT PRE SUMMALKY
1YLU 4BINr3 I?f~E -- SEWF lot -044114-M) 3t).ttCt
R
Si.fB-TM AL c;cMf RUCMDN AND Pl ,AN r'iTF X
rnr-PAID "TE!,S
S0.010
TOTAL E''tC RINUT i?.I<;F:�`S DUE NOW
$30.401
RECEIPT
DATE
BYf
DATE FINALED
INSPECTOR
I -
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 or r
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL AP ROVALS
Temp. Power- Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures'
Main Service
Sub Panels
Exterio ,Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
-JUN 21 '99 01:17PM JFK ADMIN 6197758014' P.2i2
COACHELLA VALLEY WATER DISTRICT
A 11 AA__ p� 11 CASH RECEIPT DETAIL N2 73243
rReceived From,.%_„J_�Ls-�J= ,-�, '� .•,. Date;_ �L ����
Account NO. __w Lotfs)
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Uncolleated Aaoount - Name
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❑ Bond Payment - A.O. Bond
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TOTAL $
Remarks:
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