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LICENSED CONTRACTOR DECLARATION
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
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DfSignature of Contractor a/ +� t} i �� 7
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 X I 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 KXF_AVOT 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 those provisions.
Date: {t 1�~ Applicant i�'�.f-
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. 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 fol inspection purposes.
Signature (Owner/Agent).�y/. � 1 �t'-' "`— Date f/ dAl
BUILDING PER
PERMIT#
DATE - ILUATION LOT
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0211-203 TRACT
JOB SITE
APN
ADDRESS 5I_7I5 AVEKIDA I)JAZ
- -
OWNER "" '
CONTRACTOR / DESIGNER / EN (NEER
ROY3MT AVINA
R Y3 CON,4TRUC1 ON dt DRAIN 81MVICR
51-715 .AVFNR)A DJAZ
b'215 4 TAHQ N17 -WE
LA, QUINTA CA 92253
INDTO CA
92201
1,
(760)342.9175 C131if 5839
USE OF PERMIT
PLU1 1No ,
SLPTIC, fi.liANDONlt?JM4T/SFWZR HOOX•UP.
VALUA'CION
1,m Do 1.S
Fig"MIND-W COST OF CONFIRUC3MON
3,6F34"%00
PERMITFRE I;C!?4WAY Y
PLUstfBINOFEZ GV VER 701-000.4.19.00(?
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C,TY G'r LA
FINANCE DEP'
SU.R='�OrAL C01XJTtJC'1'10]N AND 1`L-44 CF1MX
$30.00
LF -43 PRIT-PAM MW5
ISO, 00
'1'{ TAl..F'1i:.RM,1'I' FJ0,''81)1 SAS NOW
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RECEIPT
DATE /
/f 0�
BY �.ti
DAT IN
v
INSPECT
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 Wail 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
10 PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Mlater Piping
Plumbing Final
iumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection 1%�(
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
Final
Utility Notice (Perm)
coAu*sLLAVALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:
,
Address:
i Tract
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Service Address
o meter(s) $
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umrn on Charge
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Plan Check Fees Water /Sewer
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Bond Payment A.D.
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TOTAL $
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�oopy to:
Cash Water Service L
Check
Money Cashier
Order
CVWD-438 (11189)
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GEC -3-2002 09:04A FROM:
TO:93426640 P:111
EC Sewer Service, Inc. JOB TICKET e
dba ECONO SEWER SERVICE
P.O. Boa 581029, North Palm Springs, CA. 92258
(760) 346-27.93 (760) 329.7760 cuLwlnsr Urger Na Daltl i1 titin mI >5
'FBI (760) 251-3405
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MVICenav a.N'ricTANK HAS SFM IC TANK pBt'N M Ir, k;FJOWes Q No ❑ PAST UN smr..
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Pumping Fee per 1000 (;allons (or fraction)
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Waste Discharge Fee per 1000 Gallon,
Locating And Opening Fee (lhr. Min.)
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QUAS8 TRA1-S
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_n •1i1 Det�qury to tnliteq ►tlne elc►alriy eompdny .
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To remove Will up Widr. This will increase the life of your lexiirnp eylkm
0 TMS ruwLNc WQ,L rRovmE. ONLY Tr2.L'CNtAAY NLJL•'f ANU NO'1
SCiLVE CUSTOMMS SEPTIC PRuuLLm uuc'AUbb uF mu ABV Yb
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ON Al .1, RLTRUNW CEICIiS.
A MOM, CAARr.E AP I 1f1% PCR MOMTU,14% PCR YEAR, WILL 0E
CaARr,'Pun ON PAST bUE ACCOUNTS OVER I0 DAYS.
IP PAVbMNT IS OV CUEC'K
U!U'VRICti LrIC•N S'IAT'a
I Atrvby e;kpo-iee`e IM /etlrgaoq completion of the adore dreri0oc •ora:
SIGNATV AR
'Poral
Due
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