9901-064 (PLBG)N �
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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
46159 C42
/Date % ' / f 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:
( ) 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 Policy No.
GOLDEN 1-SACLE 10,4s, .Py"WC.>'!48066.00
(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 thoseprovisions.
Date: i i -;i `W/Applicant= r�'r:. • V4 _
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is.
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for.inspection purposes.
S,ienature (Owner/Agent)! //_', "' Date - l
V /r'
PERMIT #
BUILDING PERMIT
y�Q_
DATE VALUATION LOT TRACT
JOB SITE 9 �e Y��r y� * �•�.
ADDRESS 42.994) A 1=.�I11� )�1Aia
APN
77� .b��i-�j%
OWNER
CONTRACTOR/DESIGNER/ENGINEER
AT F.rNyornI-.InAi T ri)f4
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X'f"nRr(�1ET:tt(�U Srw\YT!'"0
52MO As'.ENIDA DW
840:35 CABAZOIN RD. IAtUO, CA 9220.1
LA QUINTA. CA, 92253
PALM LIES! .RT CA 922,61
f 760)'W-2793 C 13 J) 3-12
USE OF PERMIT
NY
C010RRAC7 AMOUbit C 2,;2ff0.00 LS
1
- .�:.�i`d•1tPoIX$.'ED Cloy€ OF CONS RU117FION
1".0.00
yy ��aqq��/Irr yy
8k.0.'s1E�L'['.}.�•.4 ��[��r a�di:CVaL���.A
'PLf.7MPNO.FERSEWM 1.01-000-419-000 W.00
FUB-`):'CTA!,!,;O)MI��+"9'[2FiG!ION AND PLAN C;HT;CK
LA'S'S PRE --PAM FETES
$0.00
TOTALVERMIT FRES DUENOW
$30100
nA
RECEIPT
DATE
BY 7. %j
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION j
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
'Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
ECONO SEWER SERVICES J00 WORK (ORDER
ER
192
PALM DESS ERT, CA 92261 09109
'j %0-c/ 7J \/ Vv/ Me -W-/ / vv
DATE OF ORDER
FAX (760) 347-4978
47
CUSTOMER'S ORDER NO.
PHONEMECHA
IN EASE PAY FROM THIS INVOICE.
HELPER
STARTING DATE
BILL TO
TAX
ORDER TAKEN BY
DAT&OMPLETED
WORK O D BBYY•
TOTAL AMOUNT
ADDRESS
/J! __[3 -No one home
Total amount due ❑, Total billing to
�� /f/ / I
❑ DAY WORK
'� � /
❑ CONTRACT
❑ EXTRA
CITY �
Cts
JOB NAME AND LOCATION
JOB PHONE
DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
1V4% PER MONTH CHARGE AFTER 30 DAYS_
Signature a�� for above work: or be mailed after
completion
I hereby acknowledge the satisfactory completion of work
of the above described work.
TOTAL MATERIALS
TOTAL LABOR
IN EASE PAY FROM THIS INVOICE.
BE MAIIED
TAX
DAT&OMPLETED
WORK O D BBYY•
TOTAL AMOUNT
$
/J! __[3 -No one home
Total amount due ❑, Total billing to
Signature a�� for above work: or be mailed after
completion
I hereby acknowledge the satisfactory completion of work
of the above described work.