9810-057 (PLBG)I)
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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
480961 1013> 99
r•
,Date ` ,� Signature of Contractor-T�
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).
( ) 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, 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 Policy No.
►TATS >> LND 0046-994)ut►hsa�
(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 37.00 of the Labor
Code,, -I shall forthwith comply with..�•
those provisions:,�
Dpte f n - ``i_ q Applicant % w - _ — a
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penaliies"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 property for inspection purposes.
Signature (Owner/Agent) �"�� F� Date
J
BUILDING PERMIT
PERMIT# •
99.10-057
CONTROL#
DATE I1)/ 7/9�t VALUATION �� �) �) LOT
TRACT
8404vi
JOB ADDRESS 53-725 l�.~�'�rlN�fl�A E'1E�..�f.Rll�� A
APN _ y
OWNER
CONTRACTOR/DESIGNER/ENGINEER
"i1M r3.�'t"fI' . i
Gt;ONO fiE1° ER 4FR,VTCE
�53-725 ALENf~ A MIZERA
P.U, BOX 192
Z,.P QUINI't1 Cts 92253
PAIX T)R'SEW1' CA
92261
(700)1_46-2793 �
UL4 342
USE OF PERMIT
i'1siJM-5 i NG
S:EW–Ut CONNRM, SIFT. tC M3AND0NWI917
Vfu.uis iOi�
1,500.00 LS
Ir
PC, RMIT. fTE edl1�411 ARY
PLUMBH40 FEE -- SEWER 101-300-41940 $10.00
M, C0N$rfR.UCCON,ANS
P.I.AN C3kK
53().00PAS�
LESS IMMI-11AID FEES
$0.00
OCT 07119098. If
FFIR,S DUE, NOW
$30.400
31TY OF LA QUINTA ' . .
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
,�? a'
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
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 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
est
GasT
A lia�'"
-
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
t
Final
f Urifity Notice (Perm)
COMMENTS:
COACHELLA VALLEY WATER DISTRICT
T CASH RECEIPT DETAIL' b ��
Received From: ' Date
Address:
l
Account No. Lo s) Tract
Service Address_ / �� ���{�G f�^�� G.A. Code
❑ Meter(s) 3
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ Detector Check(s)
❑ Meter Surcharge
O'Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees. Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
TOTAL 3 1 �) OAD
Remarks:
r` r I f J• l -L� 41
Dopy to:
Cash Water Service
Check
Money
Order Cashier �.�
CVWD-438(11/89)
y ECONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
JOB WORK ORDER
t ••
••
k/VVJ J'4V-L/73 klVVJ 3C0-//OVFORDER
FAX (760) 347-4978
;0--
TOTALLABOR
9
CUSTOMER'S ORDER NO.
PHONE
MECH I
HELPER
STARTING DATE
BILL TO
r
ORDER TAKEN BY
ADDRESS
❑ DAY WORK
�
❑ CONTRACT
CITY
C
cc..
[:1 EXTRA
JOB NAME AND LCFCATION
JOBPHONE
DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
1;,4a% -PER "" H- CHAR GE AFTER -20 -DAYS
TOTAL MATERIALS
TOTALLABOR
PI EASE PAY FROM THIS INVOICE
TAX
D TE cOMPLET TOTAL AMOUNT
$
/% ❑ o one home E]Total amount due
Signature 40 '0 for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
❑ Teal billing to
be mailed after
completion
of work