0404-009 (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
7W RA4 G.12 06-. 012(
Date 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).
0-A, I, as owner of the property, am exclusively contracting licensed
bontractors to construct the project (Sec. 7044, Bfrsines j& rrofessionals
Code). `� f� � _ !fA/!
( )-I am exempt undet Section , I
Date W-_0 -1)4 Signature of Own
WORKER'S COMPENSATION
I hereby affirm under penalty of perjury one of the following declarafi�vs:
() 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 E.$ M1 T 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 mnner so as to become subject to the
workers' compensation laws of California',Iand .6jrJe that if I should become
subject to the workers' compensation p t� t
'rovlslo � of Section 3700 of the Labor
Code, I s all fo `h;wit/�' comply witty
pr�o�iio s:
Date:( Applicants d -
r _1
Warning: Failure to secure Workers' Co . pensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application. - -W
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers', agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this r application nd� sntate that the above information is
correct. I agree to comply with al Cit rd tate laws relating to the building
construction, and hereby authd$z�rep e.Statives of this City to enter upon
tth ,above-mentioned pr ipert o 'insp ct'o p4 rposes.
W0
Signature (Owner/Agent /. `S �� Date• Ir�
1
BUILDING PERMIT PERMITN
DATE .VALUATION LOT TRACT
g4101l2g~'
JOB SITE
ADDRESS 'C)2,6$0 A.V.MB)A VIL.T A
APN .
OWNER
CONTRACTOR/DESIGNER/ENGINE ER
THOWS JAMIES C[:il (TETT
RIGGS BACKHOR S'FR.VIC
2•fi$!3 ,t��d F:NI1 A V S,A _,;
10520 MD OPX ROAD
L.A, QUMA CA.: 92253
`i'UCATA CA 92399
(909)797.9570 Com" IISD
USE OF PERMIT '
sL,PTIC,AFAIqDONIF,MSgIT%,'39WE•ftf;CJW'HECT, 2001 CSC,
VALUATION 5.1900.00 Lo
KS°Y'.ti�ArKD COST OF C0.149f RUCHOW
ampoom
PLUMBING M - SWEI2 1,011.000.419.000 $+41►,00
0-
SC9i TOTALO��FTT'R`i3��'i:C�� AM A" CHECK
h:30,00
' Z i9,9 PRE-PA,,ID �-S
$0.00
®
��—'
A`I_� 012004 t"
CITY OF LA QUINTA
FINANCE DEPT. z�
RECEIPT
DATE �r i 7
BY /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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
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
Appliances
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)
_.-`ryq•ya. . ... .�9,`-'tn„ )F �`I •7 j 4.tA7�'.vt
C T COACHELLA VALLEY WATER DISTRICT
t/ CASH RECEIPT DETAIL �.6._
` Received From: Cots N ,✓ � � � Date:
'. Address:"l e-J Z.A / e. CA ! V ►► j� 111 ��' �' ' �% 2 Z.. i
/ Z Q• Lots) L. h• ' f 1 1 S� Account No. %&'06 / � � � "Tract � •
• Service Address 57 6'W'W n V E L G.A. Code
Meter(s) $
A ❑ Service(s)
❑ Backflow(s)
f, ❑House Laterals)
❑' DetectorCheck(s)
OO Meter Surcharge
f`�sanitation Capacity Charge i) l ,t��" / ti }' a
�d�� d)
❑ W.S.B.F.C.
F�'• I
F, ❑Temporary Construction Meter
6 ❑ Turn on Charge
•n II ted Account - Name
❑ U co ec $y
❑ Inspection Fee - Tract -
Fee - s.
❑ Plan Check Fees Water-] Sewer -
T act - 1 a
(; ❑ Bond Payment - A.D. --Bond
As_smt. ti..
`. ❑ Customer Deposit
❑ Other !1
TOTAL $,1�
Remarks:
py72_
r
Water Service
Cash
u
Check t� 1 7? �
Money x. a;- Cashier
Order
CVWD-438(11/89) j
drawing of record.
These deviations from the, drawings :of record are beyond thecontrol .of . •
CVWD; therefore, the district will not be responsible'for •any charges.
incurred by the homeowner as•a result-of these inaccuracies.
Jury 1.2002 "