0108-168 (PLBG)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
D,k 4 *7 f �,Z Signature of Contractor r` _
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).
O I am exempt under Section B&P.C. for this..reason r`
Date Signature of Owner
11 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 pelf -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.
w ( 1)' 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.
STAT 3 FUND 1=21 -01
(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 wlth those„ prcRi'sions",'1
„6ate}7. *r Applicant +� `a - "•'`
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
,1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with. all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for,inspection.purposes.
Signature (Owner/Agent,, �'F Date�.•'w }'r,,
�. BUILDING PERMIT PERM T#
DATE + t VALUATION LOT GINA," TRACT
JOP,,SITE APN
ADDRESS o i. voFt 773 7
nvh [ 7ry efy—v71r
OWNER
.EJ — CONTRACTOR DESIGNER/EN 1NEER
.V D. & 4NdWE S, M7VlnYLIUM) 1 0 Yyi1YER ISMMIE
79.815 VVEW`i W01-10 VR.t 5403"i CABAZ.PL .1 RID, INDIO. CA 92201
PALM DEffERT CA 92261
7bf$)34S��7i�'3 i NUA 34.2
USE OF PERMIT
VALUATION 1
RMITt' FINE SUMMARY
%1,511,00 U-31
S;
?F
e
AUG 17 2001
,
CITY OF LA QUINTA
FINANCE DEPT
1 31 Z' -PAWr1Kf-3
13 11 PRE
TOTME. PER- lY 1i. EES DUE? NOW
RECEIPT I DATE i I B/ / I DATE FINALED I INSPECTOR
$30.00
$0,00
MAW
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
`
1
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel i
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval t:) Cover
Equipment Location
Underground Electric
'I
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral _ ��f
Sewer Connection "z�`�/
O.K. for Finish Plaster
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final 8 Z
Utility Notice (Gas) ! ll(�
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
' A--` `-"t.�. '.a�f'.�yyr.:2 »�y. � .{a4,r ..p•. •;�- � r.� � - r+F .-t:- � ..:.r � .�... _ ua ..br-K�- -
r , ,.. .
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL ��
- U� . IMS I i' �_: 084-28:1Received Fro
�m� '� S Date-/,
Address: l "� " �% \ \3.� Q WC, ✓3c-- - — --- -
Account No. � 0-1 -LPA \ O (1C1 U • l� Lot(s) S Tract 2-1 - i U
Service Address G.A. Code
❑ Meter(s) $
O Service(s)
O Backflow(s) -<
❑ House Lateral(s)
❑ Detector Check(s)
❑ Meter Surcharge
Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
O Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
O Other
TOTAL $ — -.� (I-• � '.
Remarks:
.tea
J _ -
Bco-py to:
Cash L Water Service
Check
7
Money '` Cashier
Order CVWD-438 (11189)
Flood plain plan
Plans picked up
_.f�.,. _ _ . , -. ,
Plans resubmitted
Construction
- - � ---
Grading plan
Mechanical
2"' Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Grant Deed
Plumbing
Plans picked up
H.O.A. Approval
Plans resubmitted
S.M.I. _
IN HOUSE:-
,4 Review•, ready for corrections/issue
Grading .
Planning Approval
Developer Impact Fee
Called Contact Person
Pub. Wks. Appr
A.I.P. f.
Date of permit issue
School Fees
Total germ it Fees