9903-147 (PLBG)LICENSED CONTRACTOR DECLARATION
1h 'eb' affirm underpenalty of-p6rjury that I am licensed under provisions of
C co
hereby
9 {commencing
pr�encl ng with Section 7000) of Division 3 of the, Business and
Professionals Code and my License is in full force and. effect.
"Lipense # y Lic. Class Exp. Date
bilte, - Signature.of Contractor'1'4;X,1111_,,^�----
,OVVNER-BUILDER DECLARATION
-hereby affirm under., penalty of perjury that I am exempt from the Contractor's
License Law'for 'the following reason:
4, -. 1, 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).
as ownero'f'the property, am exclusively contracting with licensed
contractors "'-to'66ristruct the' project (Seca 7044, Business & Professionals
Code):
I am exempt under Section B&P.C. Or this reason
Date Signature of Owner
A4 VORKER'S COMPENSATION DECLARATION
hdrbbyiaffirm under penalty of perjury'.one of the following dedlaiaiio6§':
O I have and will maintain a'c'ertificat6 of consent to self -insure for workers'
compensation, -as-pr�ovided for by Section 3700 of the Labor Code, for the
performance of the Work for which this permit is issued.
O I,hAve and will -maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the perf&Mance of the work for which this
:)erlftiit: is issued. My'workeis' compensation insurance carrier & policy no. are:
Came.r.. Policy No.
.
ZAG".13, TIZ, 111309�w
(This section need not be completed if the permit valuation is for $100.00 or le i ss).
I . certify
rtify that in the performance of the work for which this permit is issued,
1'shAll not employ any person in any manner so as to become subject tc�the
workers' compensation
e6sation laws of.,Ca.lifornia, and . agree that if I should become
subjeci to ih6`wo*rk'ers` compensation provisions of Section 3700 of the Labor
Code, Ishall forthwith' comply with Tthogbe'pibvisions.'
bdtb:'�X 4-1, Applicant�'��'—I!'"----%--..
Wa
-
rn ng.' Fa llure to see , ure Workers' Compensation coverage is unlawful and
s IC
ha subject
an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as pro . vided for in Section 3706
of the L6bor.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
plication.
_11.. Each person upon whose behalf this application is made & each person at
f" - who . se.reqyest,and for whose benefit work.is performed under or pursuant to
pny:permit issued as a result of this applicaton agrees to, & shall, indemnify
&' hold 'harmless the City of La. Quinta, its officers, agents and employees.
i. Any permit issued as a result of this application becomes null and void if
is",not commenced.within 160 days from date. of.issuance of such
riTnit, or cessation of,w.,ork for 180 days will subject permit.to cancellation.
lify that I have read this application and state that the above information is
Correct. 1. a6ree to.comply with all City, -and State laws relating to the buildirig
construction, ' * ' and hereby authorize representatives of this City to enter upon
the above- mentioned prop�qr;ty_for inspection purposes.
Signature (Owner/Agent) Date .5
BUILDING PERMIT PERMIT#.
,),90J447
DATE VALUATION LOT TRACT I
$1,4
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR DESIGNER ENGINEER
LA. 'QUINNA, RE.11NEIVY.1 r`%PM1__WfA0T'N,r_-'Y
F., C OT J 0 8L_` W M, 9 q Ft' V * I rip
79L.405 CALU T&A'41"IC0
84015 CALSAW"'N RV. GZ10, CA 92201
LA QUI.IC-A C11A 9_125J�
PAU0 I.A�Sh'frf dA 92-261
USE OF PERMIT
0011.1,17MAICT JkVIOUNT i'1130.00 LS
41� A L R.A A #."IN
101-W-419-04XI $30.00
If. K-
MOO
UESS PRE-PAID'ITEES
$0.00
RE
2 r
DATE
J
BY -
U
DATE FINALED
INSPECTOR
INSPECTION RECORD
r
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bood
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg, Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection - _
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final ,
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
ECONO SEWER SERVICES' JOB WORA. HERI.
..
P.O. BOX 192'
PALM DESERT, CA 92261 O' 213,
(/bU) 34b-L/J3 (/bU) 3Lt5-//bU
FAX (760) 347-4978
DATFOFORDE$�`
CUSTOMER'S ORDER NO.
PHONE
MECH
HELPER
STARTING DAT
BILL TO
ORDER Tr.KEN BY
ADDRESS �
2`/`
❑ DAY WORK
i ..7J
❑ CONTRACT
CITY
-
❑ EXTRA
4
JOB NA0E AND LOCATION
JOB PHONE "
Signature
PAYMENT TERMS NET 10 DAYS FROM DATE Or SERVICE
1%96 PER MONTI! GIIARGE AFTER 30 DAYS.
TOTAL MATERIALS
• TOTAL LABOR
• TAX
TOTAL AMOUNT $
A ❑ No one home,. otal amount due E)—otal billing to
j for above work: or be mailed after
completion
I hereby acknowledge the satisfactory completionif work
of the above described work.