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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
llkk
ISM I - C:411 ti�l�li97
/Date Signature of Contractor;�
OWN ER -BU ILDER.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 f 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.
N 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:
Cartier :.;' X1113 FUND 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
sub)'ect to the (workers' compensation provisions, of Section 3700 of the Labor
Cride, Fd Sh II fo tp,j th comply with those pro"visions..
/bate: [ . /!mss Applicant .' .���"�—�%_2+"�#aJ
Warning: Failure to secure Worke s' Compensation coverage is unlawful and
shall subject an employer to criminal peAalties 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'Cityjand State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
-��•� 6.r,l�
/Signature (Owner/Agentl� Date
4
BUILDING PERMIT PERMI,�Z-(A)CONTROL#
4397
DATE 12/'V% VALUATION S1,(*0.0n LOT TRACT
JOB SITE
ADDRESS XVt�,P60 �)DA 1 IX4
APN 774-26"19
OWNER
CONTRACTOR / DESIGNER / ENGINEER
f3tNO° IANI
ECt. NO fiFs'WIM St:IMCP
4041N Klv.iGHT Aittvt.i1aD ROAD
9,1035 CA1 V,0N RD.
1VI1iAlE�1iF TN
PA1,10 15t?s)?wr CA 9221 1
(61914416-21793 3.12
USE OF PERMIT
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a•r E� .-,��'IE. G l itti.!"!�11C". P'ft? : !'!Nl [1 '(�,r�{hf C[;�Y} (ryxe� pq {
4$0
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AMU. rF I�;RNs a'.t ei 1";���,N ori: E NCAV
DEC 0 2 1996
RECEIPT
DATE!
BY
DATE FINALED
INSPECTOR
IpF
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
w
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
Ap liances
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)
COACHELLA VALLEY WATER DISTRICT ���
CASH RECEIPT DETAIL 6Cn' - BPI I s 6
.: Received From: f 5 i%i . I �.(�� {� Date' _
Address: p -C) '—
Lot (s) Tract s C-
Service Addressm °_- C , 4 V S G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
anitation 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 $ '"
Remarks: Lf l ! L !! be:�� f �' jr":1Lj t , �Clt /i F) f 0
arlevy to:
Cash Water Service
Check (j 1 �zt1 -
`` Money t Cashler
L Order
''�i` C D-43E�11189)
E60N0 SEWER SERVICES
P.O. Box 192
PALM DESERT, CALIFORNIA 92261
AM MoaaoaM
EE
PHONE 315-7760 346-2793
A
TOTALLABOR
USTOMER'S ORDER NO.
PHONE
ME NIC
HELPER
TAX
STARTING DATE
DAT OMPLETED O ORDERED BY
TOTALAMOUNT
$
BILL TO
ORDER TAKEN BY
n
ADDRESS /
f
E] DAY WORK
(CCSjj� Gf! J
CONTRACT
EXTRA
JOB NAME ANOCATION
JOB PHONE
ION OF
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
2%% PER MONTH CHARGE AFTER 30 DAYS
Signature
t 25&t
Groto us Inc
rNon N 01171..
No one home ft249talamountdue
for above work: or
1 hereby acknowledge the satisfactory completion is the above described work
Total billing to
be mailed after
completion
of work
TOTAL MATERIALS
TOTALLABOR
PLEASE PAY FROM THIS INUOICS
NO STATEMENT WILL BE MAILED
TAX
DAT OMPLETED O ORDERED BY
TOTALAMOUNT
$
Signature
t 25&t
Groto us Inc
rNon N 01171..
No one home ft249talamountdue
for above work: or
1 hereby acknowledge the satisfactory completion is the above described work
Total billing to
be mailed after
completion
of work