9806-059 (PLBG)I° LICENSED CONTRACTOR DECLARATION
N I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O =) M License # LicClass Exp. Date
r- O LO !1`C(1 61 C-41 10/31199
I
r— ,`} �*(�
ZO r --ate ' 'Q Signature of Contractor :
co
J U � OWNER -BUILDER DECLARATION
W WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C0 () I am exempt under Section , B&P.C. for this reason
O.N Date Signature of Owner
rn
U—Il z WORKER'S COMPENSATION DECLARATION
C) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
In O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U (
)/l have and will maintain workers' compensation insurance, as required by
OU Q Section 3700 of the Labor Code, for the performance of the work for which this
LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Cartier Policy No.
r` p
.< (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
3. Code, I shall forthwith comply with'those provisins,,,:�;
Date: /- 6i>Applicanti, t
4b Warning: Failure to secure WorkerjE;ompensation 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
I 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 h'I�Y, .;
application.,t
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 purpos(e�s. �fy�
Signature (Owner/Agent) /� ` Date4�-
4
10
BPERMIT# CONTROL#
BUILDING PERMIT 9Mflti-t):e�
DATE VALUATION $1,473.00 LOT TRACT
7878
JOB SITE - 51--614 ,t3. Y.E1` UM, HERRERA
APN 773-133-005
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
51-60 AV.ENIDA.%3ERRl [Gt
P.O. 601K i�3'�
LA t` UINCA. CA 92253
PALM DESE10' CA. 9226t
(760)3Mji 2793 CRL4 3.12
USE OF PERMIT
t'€..tli1� 13
SEPTIC" f -t iANt:X N', SEWER CONNECT
eJ:,�'.►TUMA- 111i `i e ®I' �,� L'1 4: i vi ii r�E✓ F
�r.a to P ig
t? A1&4t3ING, 'F--, -- Sizl:9f& 101.000-4.€9-000 Rsi►.t#i
4a
c R •g
4 ti
I`'?t> t ` � x .i., C". AND PLAN C 1 11-
RIO W
t.ES`o
JUN 0 81998 t
It TOTA6 P!j h,IT up:I"'s iluId+;,'N,o V
$ 3€€.00
f OP
LA
RECEIPT
DATEDATE
FINALED
INSPECTOR
bi r
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
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 �JJ% _
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
t
Final
Utility+ Notice (Perm)
"OECONO SEWER SERVICES
P.O. Box 192
PALM DESERT, CA 92261
Phone 328-7760 346-2793
JIM 0M OEM
N2 - 8968
DAY WORK
F1 CONTRACT
0 EXTRA
PLEASE PAY FROM THIS INVOICE
t
Signature
omeTD 1 MPunt due
for above work. or
I hereby acknowledge the satisfactory completion
of the above described work
❑ Total billing to
be mailed after
completion
of work
TOTAL MATERIALS
TOTAL LABOR
NO STATEMENT WILL BE MAILED
TAX
DATE COMPLETED
WORK ORDERED eY
TOTALAMOUNT
$
Signature
omeTD 1 MPunt due
for above work. or
I hereby acknowledge the satisfactory completion
of the above described work
❑ Total billing to
be mailed after
completion
of work