9707-038 (PLBG)U)
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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
%hapter 9 (commencing with Section 7000) of Division 3 of :the Business and
- Professionals Code, and my License is in full force and�'effect? t
License # Lic. Class Exp. Date
71 /+� (_'1 c / /301.99
Date f✓1 { Signature of Contractor
j.
OWNER -BUILDER
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 of consent to self -insure for workers'
compensation, A provided for by Section 3700 of the Labor Code, for the
perf2rmance of,the work for which this permit is issued.
.(+NI/°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
permli is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
STATE F1JN0 1 ` 22997-(lfl(i0ti91
(This section need not be completed if the permittvaluation 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��provl Ions of Section 3700 of the Labor
� 3s� s:
Code, I shall fortwlth-1comply,witth tlhose•p�v to s.
Date: 1` +41,11 "I Applicant `)
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!6ys will subject permit to cancellation.
/' 1 f t,
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I certify that I have read thisapplication 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
tt 6 above-mentioned proper
lty for insp"e i' n purposes. /
)/Signature (Owner/Agent) (VI I Date"41
r 1
BUILDINGPERMIT- PERMIT# CONTROL#
i
DATE VALUATION LOT 9707^439 TRACT 5487
7/10197 S1.SQ0.00
JOB SITE
APN
ADDRESS 79_79:5 FIESTA DRIVE
649-063-003
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i.EsrF.R C COX SR.
=FFEN PI, MBING
799251~IE.91A DR
P.D. BOX 612
LA QLUNT.A CA 92253
INDIO CA 92202
(760)345-4353 CEUf 11
USE OF PERMIT
Pi.UI4i13
SPA TIC A13ANDOR 3FM CONIN-FC.`I'
ti
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VALU,i1I ON 1,51 AM LS
ESTIAIA.TCD COST OF CONSTRUMON
1.500.00
PERN9IT FRE SUNIKARY
PLIAtBIN4 FEF -- SEW Mi 101-(i()n-414-000
SUB -I DTAL c�NS 1RUC71cDN AND PLAN CHECK
W.00
/ LESS PRE -PAID FEES
S0.00
TOTAL PERMIT FEES DUE NOW
$30.00
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
j 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 Oram
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
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)
COMR)ENTS:
! - I
COACHCAS VALLEY CEI DETAIL ISTRICT 63367
Received From: ..S 'f ,J X Y Date -
Address:
!� Account No. Lot(s) ` Tract 21 � d
Service Address .j 57 G.A.•Cods
i
❑ Meter(s) $
( ❑ Services)
❑ BBacktiow(s)
Q,14ouse Lateral (a) ' a 10o_
• Q;1
❑ Detector Check(s)
❑ Meter Surcharge
q,6nitation capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter i
L
❑ Turn on Charge
❑ Uncollected Account -Name
❑ Inspection Fee - Tract -
Fee -
Q Plan Check Fees Water I Sewer -
Tract - I
❑ 'Bond Payment - A.D. - Bond'
f
Asamt.
f ❑ Customer Deposit
❑ Other
I
TOTAL
t
Remarks:
i
� I
i
f cp py to: i
Cash - Water Service
Check.
Money ` t w Cashier
Order CVWD-498(11189►