0004-190 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
•I-- r9hapter 9 (commencing with Section 7000) of Division 3 of the Business and
cv W ' 'Professionals Code, and my License is in full;force and effect.
O M License # Lic. Class Exp. Date
a� 3�$� A.�I�"=�•�`� 08/3112(
o Z r`te`rT�+ Signature of Contractor
(O o 1
J U C:) OWNER -BUILDER DECLARATION
HLULU I hereby affirm under penalty 6f;peejury that I am exempt from the Contractor's
U) License Law for the following reason:
Z ( ) 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
CY) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
FL Z WORKER'S COMPENSATION DECLARATION
o 1 hereby affirm under penalty of perjury one of the following declarations:
LO F- p () 1 have and will maintain a certificate of consent to self -insure for workers'
X LLI u- compensation, as provided for by Section 3700 of the Labor Code, for the
J Q performance of the work for which this permit is issued.
Q C) ( ) I have and will maintain workers' compensation insurance, as required by
Q Section 3700 of the Labor Code, for the performance of the work for which this
IJr)� Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carver STXrP PUND Policy No. 1103201-99
co 5
a
J
(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 agye a that if I should become
3 subject to thef workers' compeensatio. plovisions Of�Section 3700 of the Labor
Code I sh II o. hwith comply ttxose..rouisio §,\`
ff� P Y P
Date:, l `C' 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 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 pr p�..for inspection purposes.
�S�gnature (Owner/Agent) Dater ICL
`I l U" BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0004-190 TRACT. '
JOB SITE APN
ADDRESS 52-3-3.3 aA.NJ4,�MA HFPJZERA . 'I
OWNER I CONTRACTOR / DESIGNER / EN (NEER
SU81W HUNDT TifitTM} 11 , IbTG.
52 ::3 AVLM )A13L 7tA 74-990 JC)B I 3 T1 , ` t'1 2.D -
LAQUINTA CA 92253 PALMDEBMT CA. 92260`, f
(760)340.2726 CRL4 -25261 k
USE OF PERMIT
PLUNMING
SEPTIC ABANDON ISLvWPR CONNECT ONLY
W
VAWATION 1,500,00 L9
o
ES71M41% COST D1� t:D1V�7[i i1C477C11�i lgtMt oo
1p11 -TRA 1T M SUADAA Y
PI.I bl.13INGFEE 101.000-419-000 $+0:Q6
Ss`U1s=' 0TAT. C0RVrRLXn'10X AND PLAN CH8M', $30.00
LF33 PRE -PAM FFXS $0.00
DATE
TOTAL FERE ' ?FTE'S DUE 1V OVA
DATE FINALED I 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
Root Deck
Exhaust Fans
0. 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 Pibg. 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 - S— Oa
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) Ld
COMMENTS:
7.�. i>. .�', .i-r.w, . x •� i �, t.'4ts� 'x' _.�'.z x �u -. '+��r n �f.Dw . Y 4„ .�.. •.! .s {i 'n, J. _ y
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL'
Received From: —Date.
,//�� y� Ch_ t•� Date• •+
Address: P D Box /V/S6i
Account No. & /'. _Lot(s) ,, Tract
,Service Address 3 3 �%�✓Cii . llC w_le — - ° GA. Code
❑ Meter(s) « !
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check(s)
r -
❑ Meter Surcharge
_6Sanitation Capacity Charge
:❑ W.S.B.F.C.
40'Temporary Construction Meter
❑ Tum on Charge 't " • F F-T
❑ Uncollected Account -Name -
❑ Inspection Fee - Tract -
Fee -
r' ❑ Pian Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit s `�
❑ ti 1.1. r
Other
TOTAL
Remarks:
L1Copy to: TIZ
' • �
I
/���.:; Water Service ; �;�
,...v
Cashier
r• } r L_ CVWD-438(l1188I�