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9704-138 (PLBG)N W r- 0 to W C Z r� r 0 W W D_ U) Z .In U`) N ON D_ Q Z IL to Q 0 u_ X W — mUU O �M� ,qt Z wC3 Q J 'G LICENSED CONTRACTOR DECLARATION w: ;Y hereby affirm under penalty of perjury'that I am licensed under provisions of Cheer 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 Date 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). . ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals '( ) I am exempt under Section , B&P.for this reasol - Date - C' - e Signature of,Ow aer 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. (This section need not be completed if the permit valuation is for $100.00,or less). (i 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 il I should become subject to the workers' compensation provisions o.Section 700 of the Labor Code, I shall forthwith comply with those provisions. / 1 Dates-� - 7Appliear3•. _ � � �' � � Warding: 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 -It. 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 ofythis City to enter upon, the above-mentioned Drooertwdor inspection purposes. Signature BUILDING PERMIT PERMIT# °ONTR°`# 5081 DATE 41.2-9197VALUATION $500,00 VALUATION TRACT JOB SITE ADDRESS APN OWNER CONTRACTOR / DESIGNER / ENGINEER .Q[!tw DENTAR f.;Nq PO BOX 391370 USE OF PERMIT PLOW VALUXTION 300.00 LS PLLI 131"t�OFEE 13Wl-11t 1011-+.i+lt)-419--00 X3(3.00 s . e r< $M,00 APR 29 1997- �fi"t'.ti1. C)ITY OF L. QUINTA a ; RECEIPT DATE @Y DATE FINALED 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 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 FPOOLS BLOCKWALL APPROVALS - 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 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 Temp. Use of Power Final Utility Notice (Perm) COMMENTS: Mailing Address: Box 1255 PALM DESERT, CA 92261 Phone: 328-6718 / 346-6916 N? 66427 Calif. State Contrafsora' license No. 310813 _r- „7 DATE? U= V� HA2_ -� OOwner WORKMAN �– Name � �� OTenant Blllto ❑ Old Customer -E'NewCustomer Job at %Z' �`' u7 At ©� �� ` C%1� h Classification CRY lt1 d t M � Zip Clly 7�Pl�/%EGr�� C Zlp ?– ! '�' Telephone (; –> WORK AUTHORIZATION - I / We hereby authorize the work described along with the necessary materials and parts WORK ORDERED: Time From To Hours MATERIAL USED AMOUNT Mon. Tues. Wed. Thurs. Fd. Sat Sun. /� v Total Hours ENTERED Invoice Journal Ledger Cards WAIVER OF RIGHT TO CANCEL Having Initiated a contract in connection with emergency repairs or service for the immediate protection of persons ar real and personal property. I hereby state that the fgllowing cY srWation exia regwnng Iminlate attention: t� e�knowlted�geannd erebyywatiive al�ghtttlo mel the sale within three days. Dated BuyefsSignature TO OUR CUSTOMERS: Service men are required to have work slip signed. This is done in order to protect you, the workmen, and ourselves, and to enable us to giveyou absolute satisfactory service. You are respectfully requested to examine material and labor statement before workmen goffice leave the Job, and if you find everything satisfactory, okay this ticket �Iff servicesee to Is unsatisfactory, in any wa , please phone our Immediately.ree to chaarg�es for collection, e gime and includin arial charged ttorneys fees in the of my default' A PENALe on TY WILL BE CHARGEand further D AT THE RATE OF 1trz0% PER MONTH ON UNPAID BALANCES AFTER 30 DAYS OF INVOICE DATE. ANNUAL PERCENTAGE RAT 1896 Contractors are required by law to be licensed and regulated by the Contractors'StateLicense Board. Anyquestionsconcerninga Sig contractor may be referred to the registrar of the board whose address is: Contractors' State License Board, 9835 Goethe Road, gy Sacramento, CA 95827, P.O. Box 26000, Sacramento, CA 95826. Total Ma1eriaf Tax Service Permits- Irtsuranoe Trucks -Equipment TOTAL 0 1995 by John B. Reeves & Son Resoes BUSINESS FORMS -8MWemer Ddre.CuImrCky.CA== Fonn 31 WAC .. . ;,a, Received From:. Address: L Account No. Service Address ❑ Meter(s) ❑ Service(s) a. y, i V. i COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL S 276 i - — G.A. Code } ❑ Backflow(s) C ❑ House Laterals) 4 ❑ DetectorCheck(s) j ❑ MMoerSurcharge IL Sanitatlon Capacity Charge -7D 92S. j ❑ • W.S.B.F.C. .+ ❑ Temporary Construction Meter ❑ Turn on Charge { ❑ Uncollected Account - Name { ❑ Inspection Fee - Tract - ; ' Fee - b Plan Check Fees Water / Sewer - 1 Tract - .' ` s 0 Bond Payment - A.D. - Bond 1 Assmt. i ❑ Customer Deposit ❑ Other r Remarks: 7/M42 ILMI L.. A14 ?l;%i7/ -6/\/ /, I l/ IC f { a TOTAL $ r .:i PJ Copy to: Cash Water Service l Check 49 1r 3 Money Cashier Order CV D-438(11/89)