0302-064 (PLBG)- 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
:Pmfessionals Code, and my License is in full force and effect.
Licence #1 }} Lic. Class Exp Date Apr
B
,,,Date Signature of Contractror
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 EXI,APR, Policy No.
(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•p.rovisions of Section 370,0 of the Labor
Code,I sh II ortlfwith comply with.,those provisions. i f f
Date:' Applicant�r'"�'} " �r�
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 property for'inspection purposes.
Signature (Owner/Agent) C' {-f Datev``6�`%
BUILDING PERMIT PERMIT #
+
DATE r 3 VALUATION
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OWNER
CONTRACTOR / DESIGNER / EN (NEER
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CA' 92253
NAD10 CIA 9220 .,.:
(Y6V)342-9M C„B1,#
5839.
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USE OF PERMIT �% (
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V.1>aLUA TIO '
1,809.00 is
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X971F.s1ATED COST OF Ot:<JISTRUC310N-
3.}itMM117M S [J13WAR
$30.00
PLUM1 ING FRS? -- `7EWNR
101-000-41,94160
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FEB
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50.00 •
p 2003
OTAL YRRAW 1 :S8 13T1.1, NOW
,00 '
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
-x
BY
r-
DTE FINALE
L
INSPEC 0
Q
1@F-.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
a' 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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
(final
I I
Gas Piping
PLUMBING APPROVALS
Waste Lines
Gas Test
Electric Final
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
r
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
L
Final
COMMENTS:
Final
Utility Notice (Gas) y
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)
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COACHELLA VALLEY WATER DISTRICT
P
CASH RECEIPT DETAIL
,1
Received From: C
-e •
w: Address: � � i � ' j �C. N i � (w .
V e; e*A j
Account No. •
C �i
Service Address
" ❑..Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House.Lateral(s)
❑ .betectorCheck(s)
❑ Meter Surcharge
;ASanitation Capacity Charge
5
- ❑ W.S.B.F.C.
' ❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
'j
❑ Plan Check Fees Water / Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
_. ❑ Other
r -
Remarks: \,tq Afi ..
y. pCopy to:
Cash
Check
Money ,
Order • t.
93411
G.A. Code
TOTAL
'�- 66)
Water service
If
r f
Cashier °
_ CVWD-438(11/89)
EC Sewer Service, Inc.
dba ECONO SEWER SERVICE
P.O. Box 581029, North Palm Sprin ;jft 92258
(760) 346-2793 (760) 328-1450
Fax (760) 251-3405
JOB TICKET
BILL TO R—� C7 /' o j'J � �l `/� 'PHnO'N,E t '
ADDRESS __2o �M ' OFMC) i T�LDnC E
CITY L HELPER
JOB ADDRESS
SERVICE ElPUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP?-0'YeS ❑ No ❑ PMT. ON SITE
REQUESTED ❑ PUMP SEEPAGE PIT AT ITS RISER ED -OFFICE BILLING
❑ PUMP GREASE TRAP ' ❑ Yellow Cust.
❑ OTHER ❑ Yellow Office
QUANT. DESCRIPTION OF PRICE AMOUNT
laces
Pumping Fee per 1000 Gallons (or fraction)
I 5
G
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee (lhr. Min.)
Out of Area Fee
GREASE TRAPS
❑ RECOMMEND INLET/OUTLET/BAFFLE REPAIR
❑ EXCESSFVEGREASE/FOOD/DEBRIS.
EXCESSrVE ODOR.
RECOMMEND MORE FREQUENT PUMPING.
❑ RECOMMEND LINE CLEANING.
SEPTIC SYSTEMS
❑ THE LEACHING SYSTEM HAS FAILED.
❑ THERE IS AN OBSTRUCTION "UPSTREAM" OF THE SEPTIC TANK.
It will be necessary to contact a line cleaning company.
❑ WE RECOMMEND MAINTENANCE PUMPING OF THE SEPTIC TANK EVERY
❑ YEAR ❑ OTHER YEAR ❑ 2-3 YEARS
To remove built up solids. This will increase the life of your leaching system.
❑ THIS PUMPING WILL PROVIDE ONLY TEMPORARY RELIEF AND NOT
SOLVE CUSTOMERS SEPTIC PROBLEM BECAUSE OF THE ABOVE.
❑ CUSTOMER HAS BEEN GIVEN AN "EXPLAINATION' PACKET.
A SERVICE CHARGE OF S22 WILL BE DUE
ON ALL RETRUNED CHECKS.
A FINANCE CHARGE OF 1 1/2% PER MONTH, 18% PER YEAR, WELL BE
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
IF PAYMENT IS BY CHECK
DRIVERS LIC. # STATE
I hereby acknow edge.the satisfactory c tion of the above described work:
SIGNATUR7%i (��
Total
Due