PLBG (9901-061)52860 Avenida Martinez
9901-061
LICENSED CONTRACTOR DECLARATION
U I hereby affirm under penalty of perjury that I am licensed under provisions of
:r Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
O M ch License # Lic. Class Exp. Date
W 7461 i C42 W91OG
Z r-- Dater 1 t' ' + Signature of Contractor
c o0r-
LP
J U (0 OWNER -BUILDER DECLARATION
W Wd r— I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N License Law for the following reason:
Z_ ( ) 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
LO
N Date Signature of Owner
ON
C7
z
WORKER'S COMPENSATION DECLARATION
C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations:
U-) O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W = compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m QU (44) MI have and will maintain workers' compensation insurance, as required by
O0 Q St biion 3700 of the Labor Code, for the performance of the work for which this
d H permit is issued. My workers' compensation insurance carrier & policy no. are:
I'* Z Carrier Policy No.
d
f7f.'i.i.fAi3V X:i'iC.3i,tS l(:i J, l.\ w f; ,si ia+(iiJ{S-tfi
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(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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
I ate: 1 • !"`Applicant
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.
S*dnature (Owner/Agent) f Date
V de
BUILDING PERMIT PERMIT#
DATE VALUATION Sliw.w LOT TRACT
I . i ?.
A SIT ,
ADDRESS .pfd -960 AVENIDA MA NE2•
APN
77j-332-067 732-67
OWNER
CONTRACTOR/DESIGNER/ENGINEER
J ATME C ASt"I;. LON
1"C, ONO SI E11%.:;I 1c V!CE
52860 A,VENIDA NIAR1'IN:EZ
8,1035 C.Affi ION Rid. INDIO, CA 92201
LA QIJINTA CA 9225:3
PALM DESERT CA 92201
(7oop,1 -27in CRIA 342
USE OF PERMIT
Pj U1:Nia`
SEPTIC ABANDON. CONivi:Z17 (T.0 -MOD PRO3I;C"I' #98-26)
cc
l
/ n7+ r t r nf1 p
CONi[t.f C1 QVI!- U k 1. 5oa.00 t.1
N
R
E.QP a'IMATED MST OF CONSI,I:t1CI<'ICJ,N
1.i0{S.tlt
PERMIT FEE SUMNIARV
1,11.1[jujiIN:} t:i b__ SE.WeR 10140 419-000 31► t!)
St ll-ly.1TAI, CON',' YJI rC'ITON AND PIAN CHECK
on
LESS PRE -PAID HMS
$0.00
€OiAt, f'ERWEi't< krEI!!S DUP,, hir`3W
$30.00
RECEIPT
DATE
BY 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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
COMMENTS:
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)
ECONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
JOB WORK (DROPq
10887V
(/bU) 34b-L/9J
(/bU) 3LtS-//bUDATE
FORDER
FAX (760) 347-4978
-:3 -5,9
CUSTOMER'S ORDER NO.
PHONE
MECHA
HELPER
STARTING DAT
BILL TO
ORDER TAKEN BY
ADDRESS
77
❑ DAY WORK
❑ CONTRACT
CITY(
`/- .` `
❑ EXTRA
JOB OME AND LOCATI
JOB PHONE
UtsGHIN I IUN Uh WUHK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
1%% PER AAONTII-CIarra7cGE AFTER 30 DAYS.
TOTAL MATERIALS
TOTALLABOR
TAX
TOTAL AMOUNT $
❑ No one home Totm al amount due ❑ Totbilling to
above work: or be mailed after
Signature
completion
I hereby acknowledge the satisfactory completion of work
of the above described work.
E. C. Sewer Service, Inc. dba
Econo Sewer Service
PO Box 192
Palm Desert, CA 92261
(760) 346-2793 or 328-7760
Fax (760) 347-4978 License C-42 #746159
Date:
RE: City of La Quinta
Project 998-20
Sewer Connection
4i
f
I UL(O-Ya,'the owner of property at V ` ' -
( Print Name) (Print Address)
in the City of La Quinta, release Econo Sewer Service of responsibility for restoring my property to
to it's original. state prior to the sewer connection. Please note the following areas they are
released from:
tj
2.
4
• 11,-
Sgnnatrue of ;no Sewer Service Employee
nature of Property Owner