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LICENSED CONTRACTOR DECLARATION
Zl 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
ate1-� x.34 C5 % C. ' &30/99199
a Signature of Contractor
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).
( ) 1, 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.
CNA zf�,ks.a taa
(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 pro •lams of Section 3700 of the Labor
Code shal foff.�hwith comply with tl p o ''si'ons.
DaApplicant
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. 7,
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. Q^
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 re sentatives of this -City to enter upon
the above-mentioned propert%y�fo p c I n p1urposes.
'Signature (Owner/Agent) ' •� Date--
BUILDING PERMIT
PERMIT#
CONTROL#
'JL�Uil;7
DATE VALUATION b1,%00 00 LOT
TRACT
.7721
JOB SITE
ADDRESS i� I � � ,C)��d :� iS�t
APN 773-326-01,7
OWNER
CONTRACTOR / DESIGNER / ENGINEER
DEBBIE r ERI Y; :-1.N 1 INIO SITS
DES�I.R'r rmc.
TKERNTA't, CA
9:.'274
(760)"199-:5194
1513
USE OF PERMIT
i'URNI,Irg
S "sf° 1.t fiHAm)oo. si Wlaic &)NatJ ' m
t1X tiA` tOM
1.50.00 %S
IPLUaf13"iNc 't?I:b -_ u1 �t> !t 101-000419-000
vi fit t e 'MAL C OIN1,51'(\tf{.;7'iON
ANID P,7_,\N
LESS
$0.00
MAY 0 19 ' $ a f(). XL, PERMIT s+'f+;EN 11)u.R 1N'+C w
& .
1OF LN
9&CEIPT
DATE V
I BY
DAT INAL
INSPECTOR
,.
INSPECTION RECORD
OPERATION
F77DATE
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 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 7
Encapsulation
Gas Piping
Gas Test
Appliances
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
4
Final
Utility Notice (Perm)
Final
COMMENTS:
,:. r:•---3'j':�:�i�'[:S.•/, �;--c-rrr..-,E -: -oT';" .=-r�--7..-�—::T_—i__ Sn;,.y �-�sf-�' '^}:i-;jY..t?%.;-. �rE+�--�7r.^ysn�+"'s:Y,•ca-�+:"7c�rr _v'�iv�.-r---.---.+.^
.�.... _. `�`•',`'¢_ :.'f3:q_'i .��+' .ala
COACHELLA VALLEY WATER DISTRICT
/ CASH RECEIPT DETAIL i� 6 % 10 9 �"
Received From: N /'/ K, 4.jeura
Account No. Lot(s)
Service Address S Z" 2 `� �_� C...E n l• L.Iha ice✓ r Q�
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
t,�anitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. Bond
Assmt.
❑ Customer Deposit
❑ Other
1 ract
G.A. Code
TOTAL
Remarks:
❑Copy to:
Cash Water Service
Check 0 1'? 7 (S Iy-,
Money Cashier
Order
CV W D - 438 (11189)
F• V
®TG— AWAY G L ~ E D
PNO O TROUBLES DOWN TH ��H 7
J100TER® Sin" 183SI WORK ORDER N0.
PLUMBERS
❑HEMET (909) 658-8541 C1 LAKE ELSINORE (909) 674-2312
❑ BANNING (909) 922-9491 ❑ RANCHO/TEMECULA (909) 699-0555
Toll Free: (800) 491-7686 ❑ BEAUMONT (909) 845.3338 ❑ REDLANDS/YUCAIPA (909) 797-8697
l Fax: (909) 652-9515 ❑ PERRIS (909) 657-9852 ❑ PALM SPRINGS/DESERT HOT SPRINGS (760) 322-2622
Remit to: 796 N STATE ST • HEMET, CA 92543 ❑ SUN CITY (909) 679.8919 ❑ INDIO/PALM DESERT (760) 346-1736
i}
JOB NAME
----------- ❑
JOB ADDRESS �.
PRICE
FLOOR DRAIN .....
ED ACCESSED VIA:
CITY
-STATE ZIP
PURCHASE`ORDER NO.
DATE JOB #3
SERVICEMAN 1
c .Y.� J
SERVICEMAN 2
'r DAY GUARANTEE (SEE BACK PAGE)
MAIN LINE
----------- ❑
BATH SINK ----------❑
PRICE
FLOOR DRAIN .....
ED ACCESSED VIA:
CAUSE OF STOPPAGE: TIME:
FIXTURE
TOILET ...............❑
CLEANED:
KITCHEN SINK .....
❑
FLOOR SINK ........
❑ DRAIN ------- ---------- ❑
ROOTS --------------❑ IN
BATH TUB
........... (_-)
LAUNDRY ............
❑
AREA DRAIN .......
C1 CLEAN OUT -------- [I
GREASE ------------❑ OUT
SHOWER ............ C)
URINAL ....... -......
❑
OTHER
VENT .................. C1
OTHER
PART NO.
QTY.
DESCRIPTION
PRICE
PARTS TOTAL
TAX
TOTAL
aCREDIT CARD ❑ CASH ❑ CHARGE ❑ CHECK #
CC #: -
EXP DATE:
AUTH. #