PLBG (0110-230)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
^Cfi'�pter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License
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iic}. Class'+ l Exp Date
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Date Signature of Contractor
OWNER -BUILDER DECLARAT,LON
I hereby affirm under penalty of perjury that.l 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.
�11� ,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 ;3't9',FJ2d Policy No. 9M9-J)•%1021�dd
(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 l should, -become
subject to the workers' compensation provisions of Section 3700 of'the Labor
Code, I shall forthwith comply(with those provisions.
Date: C,1 ):. fl)i 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,propertyfor inspeciition purp1o�s��
ft ��(:
Signature (Owner/Agent) % �� r may`'�� Date/
JJBUILDING PERMIT PERMIT#
DATE ! VALUATION LOT C-� TRACT
JOB SITE APN
ADDRESS 51-431 A ... 3ANAMAR12.0 773-4011-011
OWNER CONTRACTOR / DESIGNER / ENGINEER
51.4511 AIM, XAVARR b 41575 .j' ,wCANNO RKR:04MLA
CA 92 25 3 PAT.I.A.AMAGS CA. 92.264
(760)327-220() C�''R;A ,1',57 7
USE OF PERMIT
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V.ALIRAMAP
.,109.90is
.1'FRMR.Z ZITY. �,d 1 "(.`.Acid
PLUMBING FEZ
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Z:
NOV 2 8 2001
OW -A OWER.!XTPI,Z1plNARD PLAN CT- CK
L11113151 FIIRR�FA.1315W,5
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RECEIPT DATE/ ! BY DATE FINALED INSPECTOR
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$0JD0
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INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATEINSPECTOR
BUILDING APPROVAL'S
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
Sewer Connection I
Gas Piping /C3
Pool Cover
Encapsulation
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
17r%nl �ds_27gs 17srn �2A_77sn
JOB MORE ORDER
13820 A
` r
FAX (760) S47'4978
DATE OF RDER
DISPOSAL FEE
SERVICE CODE
PHONE
TECH N
HE PER
STARTING DATE
BILL TO -
TYPE OF WORK
e� Y,
❑ CLEAN DRAINS
❑ OTHER
ADDRESS
$ I
❑ SEPTIC TANK
❑ GREASE TRAP
CITY
w
❑ SEEPAGE PIT
JOB NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMQ UET 10 DAYS FROM DATE OF SERVICE 11h% PER MONTH CHARGE AFTER 30 DAYS.
DESCRIPTION OF
CONDITION OF TANK BEFORE SERVICE
_ Good _'Tfrash & Garbage _ Excessive soap
Fair _ Overflowing _ Sand
Poor _ Blockage _ Repairs Needed
_ Very Poor _ Odor
_ Roots _ More frequent service ne ly l/
TOT PUMP
DISPOSAL FEE
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TOTAL MATERIALS
DATE COMPLETED
WORK ORDERED BY TOTAL AMOUNT
$ I
❑ No one home ❑ Total amount due ❑ 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