PLBG (0110-229)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Lha`pter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect. ,r
License # Lic. Class-- Exp'.Date
f
Date J � �-�" r�`'>,Q f_`r Signature of Contr gcto„�,r�,����:�,-��'`
OWNER -BUILDER DECLARATION '
1 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.
(kk J� I have and will maintain workers' compensation insurance, as required by
S�ctton 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 57A.'rE pLjAf.O Policy No. 044-0i-091!3;;;0
(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 shouldibecome
subject to the workers' compensation provisions.,of Section 3700 of th'e Labor
Code, I shall forthwith comply, with those provisions., <.
Date: •A j:.. , ,� ApplicantKA -4. A -' ✓ R; � ra
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 ofkhis City to enter upon
the above-mentioned:property for inspection purposes
ll
Signature (Owner{ ge'»"^ "?�"%"��'�'" Date��
G
,BUILDING PERMIT PERMIT#
DATEl % VALUATION LOT 'S-� TRACT
JOB SITE APN t
ADDRESS 51-4�+.xJ'VE�1.1�AMUMMA I 77.'Ne'.3-0013
OWNER
MR. 3W-WDOTOAMMAR
. IUW'. A
USE OF PERMIT
PLUMBWO
CONTRACTOR/DESIGNER/ENGINEER
F3'�±.4�.AM 1iW0b7H;1M40 .% Cc NEST .
4575 K C.`MWO P&ROCZ,ltA.
CA. 92253 PA 3YNT -CA, 92264
(760j,V-2200 . MA 3,577,
SEP'i'K:'AHAt'd?1 ON. S,9WFX,1 HOOK -VP (14Wt'A.0D PAOJECT 201.004"
`ia'AYAJ.AT ON
4r,00;00.1,S
3*r.ii ;F3i s 101-000-419-000
:s
11, 3
NOV 2 8 2001 �
Olgl.iY^ ,y.E.A}�.e t.1,i1'6A7�S=i.�C;bJ,1/A'9 19� 11d�L' V MR Xi
RECEIPT DACE /' �. "1 I<BY IDATEFINALED INSPECTOR
2,M9,00
$30.01)
$0,00
*130 v
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 Flrewall
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
Sewer Lateral
Sewer Connection �% _�
O.K. for Finish Plaster
Pool Cover
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:
EC SEWER SERVICE, INC.
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261
(760)346-2793 (7601328-7760
JOB MORE ORDER
13822
FAX (760) 347-4978
TOTAL PUMP
DATE OF ORDER
DISPOSAL FEE
9_02
SERVICE CODE
PHONE
TEC IAN
HELPER
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
STARTING DATE t
BILL TO
DATE COMPLETED
TYPE OF WORK
J
/C� 7�'
$2,3Y
J
120-
❑ CLEAN DRAINS
❑ OTHER
ADDRESS
/
J
❑ SEPTIC TANK
E] GREASE TRAP
CITY
r�
�
❑ SEEPAGE PIT
JOB NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS L4ET 10 DAYS FROM DATE OF SERVICE 1'/2% PER MONTH CHARGE AFTER 30 DAYS.
DESCR
I
CO TION F TANK BEFORE SERVICE
_Good —Trash & Garbage _ Excessive soap
_ Fair _ Overflowing _ Sand
_ Poor _ Blockage _ Repairs Needed
_ Very Poor _ Odor
_ Roots _ More frequent service n9dgd
"_Tr
/"'
one home E] Total amount due E] Total billing to
Signature for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work
TOTAL PUMP
DISPOSAL FEE
tv
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
DATE COMPLETED
WORK DERED BY e__
TOTAL AMOUNT
i
/C� 7�'
$2,3Y
J
120-
"_Tr
/"'
one home E] Total amount due E] Total billing to
Signature for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work