0008-407 (PLBG)F_
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LICENSE? CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapte a 9 (commencing with Section .7000) of Division 3 of the Business and
"1ProfesAnals Code; and'my License is in full force and effect..
License # Lic. Class Exp. Date
5,422,11 ; 55 C36 C'42 f t 4 2(
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-Date �'� Signature of Contractor -*�-
i
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am,exempt from,the Contractor's
License Law for the following reason:
( ) 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).
( ) 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:
Carver FIRM"s CSL;]Nib 1W Policy No. W.PSO799747
(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 pr visions of Section 3700 of the Labor
�?
Code, al fort�,}w�th comply with thos ovision .�4.-•--
Date: f L 1I Applicant—
Warning: Failure to secure Workers' COWensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the costof 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. f 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,f r inspecti n punt10 Vis.
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:Signature (Owner/Agent) `�'•r✓ �+ F Date a`J f`U
BUILDING PERMIT PERMIT#
DATE VALUATION LOT (low V107 TRACT
JOB SITE
APN
ADDRESS 4460 DIM POINTS ROAD
- -
OWNER
CONTRACTOR / DESIGNER / EN INEER
TED HAR'IVETT
Rcri'C) P1100Tify
46.160 DUNE PALMR.OAD
796 N'010M, ST.
LAQtTiiAT A 0A 92253
]EEMff CA 92543
(909)WS-854 l CBLO ? 060
USE OF PERMIT
i''L�t:Ttft'3
SEPTIC TANK. ABANDONMENT •NEWER H0DK-UIQ
VALUATION La
EFUMA ID COST OF 00.1191 UC 110-11
4, 5i3 CK)
PERBU ME SUMMARY
PLUMD)NOISLE SEWER l01-OW419•000
ALIG7 3 0 2%L'13
•� a
i2ilC7D 'CHECK COMM TJN
,I
LF130 P.RRE-PAID :FEES
w0. ttfJ
'4'OTAL PY3CWT YLVS DUE -14 OW
� 4QIFt�
RECEIPT
DATEBY
DATE FINALED
INSPECTOR
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I�JSPECTI�JN 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
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
BLOCGZWALL APPROVALS
f OOLS a 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 vp
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
COMMENT
L .Bpi
�1
fi t
Temp. Use of Power
Final
Utility Notice (Perm)
J %__ —I
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From:
Address:
Account No. -
� Lots)
Service Address - /'!r%iJ
�Lt..iZ_r
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
V� House Lateral (a)
O Detector Check(s)
❑ Meter Surcharge
In/Sanitation Capacity Charge
❑ W.S.S.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge
❑ Uncollected Account - Name
❑ Inspection Fes - Tract -
Fee -
❑ Plan Check Fees Waterl Sewer -
Tract -
O Bond Payment.- A.D. - Bond
Asamt.
❑ Customer Deposit
❑ Other
Remarks:
ecopy to: �
Cash
Check
Money
Order
E
S, 5C'U ct
TOTAL
WaterSerJ ce(
' Cashier