0110-212 (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.
Llcense # Llc. Class , _ Exp. Date
.,lT"@ G`+y71, ',l;;E� ,.eNA 02111,21M VDat r. Signature of'Contrac1 �1^�` "''
OWNER -BU
I hereby affirm under penalty of perjury that I arritxempt 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.
(Q I have and will maintain workers' compensation insurance, as required by
Sedtion 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,.0'.f'.t TR YVNI 3Policy No. 044 .1400224
(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 C-Plifomla; and agree9,th'at if1 should bedome
subject to the workers' compensation provisions of Section 3700,df the Labor
Code, I shall forthwith comply vth,those provisions.
Date: f APPllcar;�t-/i
Warning: Failure to secure Worke.s' Com`pe sation coverage is unlawful and
shall subject an employer to criminal penaljies and civil fines up to $100,000, in
addition to the cost of compensation, dalx{ages 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 tF is/City to enter upon
the.above-meniioned4operty for inspection purposes: -t'
Signature (Owner/Agent)' %' �,� �€" ��p `fi'f`date t � 1
PERMIT - PERMIT #
.
,BUILDING
Pb �.Ci-�
ATE f VALUATION LOT ,TRACT r
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ADDRESS f«.+•' f �r Y���d '<:�i. yj,)
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OWNER
CONTRACTOR / DESIGNER / EN (NEER • y'
'79-V5 VfaTWAXI)11;0 DMVE
4,575 X CAMINO T'AROCEM.
L!% t}t7m'M1 CA;L2 3
RALA6 �f1 CA c�2"6'f.
('36OY328-22'0 ► L7 " :3577
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USE PERMIT
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Sffel.l.C:AY)lli t�
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S1AP`t`ft: ,fl,FiiANDO1,f, ShiVER HOCK -UP (LU"1h%M0* PYA11. -V Cr A401.004' � =" �
OV 2 8 2m0 01,-
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V ALtfAT10p4 2000.0412
-
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EST MATED CO&k OF C0146TRE-010N
X04 43fP .t
P.P.11aar FEV 1 1'2Y
FILUM DING FEE 101-0001-419-0010 $30'00
SUB-TMAL C:is6NS`,iRAfC"`°C109PaM PIL,NW,
$30.00
RECEIPT
DATE' I
BY
DATE FINAL,
INSPECTOR ('�
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
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
1
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)
COMMENTS:
o`` gtlio
' Building & Safety, Department
of9 78-495 Calle Tampico:
PO Box 1504
La Quinta, CA 92253.
i (760)777=7012 voice - (760) 777-7011 fax
FACSIMILE TRANSMITTAL
T ,� l r C/� ' / ED RANDALL
TO: SCJ O 4zA / y ,J/ 1 V%/��s FROM . -,c COUNTER TECHNICIAN
PHONE: 4TrV.• )E.di✓y C1 of DATE: Of
'FAX: of y9- 8� 6 - ZbZ�O PAGE 1 OF: a
SUBJECT:,Sewe2►:✓�L CC:
MESSAGE: J CNAI y
ay► c 6ii✓PEAM � T" b110- 2/L' {n. Ccwye-L ,�✓
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•
LICENSED CONTRACTOR DECLARATION
to 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
U)
C14 Lu. Professionals Code,- and my License Is In full force and effect.
ih License # LIc. Class Ex
p,Date
t-- CY LO
r*-' Lu IWI A Z, AM4
C,
Z0. Itr P:f r14 �2�1
Dat Signature ofto.nrac r
1 -
OWNER -BUILDER DE L k ION
(D
LU LU I hereby affirm under penalty of perjury that I a exempt from the Cbritract6ir's
U) License Law for the -following reason:
Z_
( ) '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). -
( ). 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
CV) am exempt under Section _, B&RC. for this reason
Ul)
C\J Date Signature of, Owner
O,
C\J
.0 0)
CL < WORKER'S COMPENSATION DECLARATION
Z
1 hereby affirm under penalty of 'perjury one of the following declarations:
U')cr
, FZ 0 ),.1 have•and will maintain a -certificate of consent to self -insure for workers'
X ui � compensatiori, as provided for by Section 3700 of the -Labor Code, for the
0 _J < _J performance of the work for.whi6h this per'mit.is issued.
M _J
< I have and will maintain workers' compensation insurance, as required: by
O 0 on 3700 of the Labor Code, for the performance of the work for which this
L LO *p6,r*mit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier
z Policy* No.,
. STATE PVHD
ob
0
(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 p6rmit is issued,
I shall not employ any, person in any manner so as to become subje5j,� the,
workers' compensation. laws of C# mi%, I and agreeJh'a't if'' shoiyj"yome
subject to the workers' compen,99tion prov(sions�'of 0ection 47001& . 0 Labor
Code, I I shall fort pwith complyit - those provision
Date: 7 Applinnit -,.e
Warning: Failure to secure Worke s' Coep sation coverage is unlawful and
shall subject an employer to criminal pqnal i s and civil fines up to $100,600, in
addition to the cost of compensation, d ages as provided for in Section 3706
of the Labor'C.ode, 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.
4. 1. Each person.upbn 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 relatJing to the building
construction, and hereb `
y"Qkorize representatives of thnil /City to enter upon
the. above- mentionerp ro erty for inspeqtion pLirpolp'es..-
Signature (Owns Ag t)
Y,
BUILDING PERMIT
VALUATION LOT 1 $2AWAII .9
JOB SITE?' i. V
ADDRESS
"S.rWAM ]at
OWNER
79-8751.VMWARD DO DRIVE
L.f-� QUW-4 CA 92253
USE OF PERMIT
]MITUD-W-0
SEPTIC ABANDON, SMIM HOOK-UP
VALUAT1011
OnO417 A I
.JR CT
I APN
4TRACTOR / DESIGNER ENGINEER
DaMolm MGMIT"G a CONST,
4575 X MaWOPAROCEIA'.
PALUSPmas CA
Z00. 10D U -
MWATM CO.W 01- C0fl'q91!=011W
NEMUT FU 8-0-MMARY
PLUMBINO FU 101-000-419-000
SOV 2 8 20'01
SUB-TMAL C01MKOMON AM PLW (2-MCK3f f,Ui1
IS= M-PAWMZ
TOTAL PMUUf IMES DUE NOW
RECEIPT DAT
1BY DATE FINALI L9 INSPECTOR
1 /2- I I C,