PLBG (0110-228)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Imo- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
C14 W Professionals Code, and my License is in full force and effect.
C) License # Lic. Class� Exp: -Date r
LO
Z � Date Signature of Contrac pr
CID O
J U
C:) OWNER -BUILDER DECLARA ION
WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
to 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).
cO
Ln I am exempt under Section , B&P.C. for this reason
N Date Signature of Owner
ON
D)
d z WORKER'S COMPENSATION DECLARATION
C) I hereby affirm under penalty of perjury, one of the following declarations:
p () 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 � Q performance of the work for which this permit is issued.
m Q 0 'e I have and will maintain workers' compensation insurance, as required by
O U Q St?ction 3700 of the Labor Code, for the performance of the work for which this
11 rn H hermit is issued. My workers' compensation insurance carrier & policy no. are:
19t Z CarrierPolicy No.
cb 5 �ii�'rTF,y qD 044.01-WIN24
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J
(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 provisions of,Section 3700 of the Labor
Code, I shall fo hwith comply wi4F those p6isions,. ,
Date:�.d t' `..fes; f. / APPlicantr/ �~;..�1$77" �,��'>
Warning: Failure to secure Workers' Coa-pensation 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 ofAhi"s City to enter upon
the above-mentioned,property for inspection purposes!
�
Signature (Owner/!�
A`gen�), ��''"- •- � ��,,✓�',
BUILDING PERMIT PERMIT#
hSJ ._.. C
� '
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 52.-03 AWENWI1.NAVARRO
'77.g-149, -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
3 4.622, AVE, 2�',i►�iVMR0
4575 X C}`.I O PAv�t?L:��.�A
'IA qu k':: CA 922"3
YA M1 9PIRMaSD' CA SJ2 264
3577
USE OF PERMIT
K"CI'�Y+ . Will
``a"KP'l1 .,ABAiNtX)N, SlzittJPER, HOOKUP (Tc.EMM00 #ylr'.OaEC" 2401.1104)
5'.IUMBDIL 9P it9 e pii9-ObA $30,00
X
1
NOV 2 8 2001
SUB-TC'irAl f-".C7NS'�2,ELTC1.111 tea AMID Pl',,t' q �"WXX
zEM! M -PaasFEWS
Saco
RECEIPT
DATE /1 J
BY''^
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
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 %jam
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final TZZY L
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
aTemp. Use of Power
afinal
Utility Notice (Perm)
COMMENTS:
EC SEWER SERVICE, INC.
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261
(760) 346-2793 (760) 328-7760
JOB MORE ORDER 11
13812
FAX (760) 347-4978
DATE OF ORDER
SERVICE CODE
PHONE
TEC AN
HELPER
STARTING DATE
BILL TO
TYPE OF WORK
r
❑ CLEAN DRAINS
❑ OTHER
ADDRESS
Z �. "
❑ SEPTIC TANK
❑ GREASE TRAP
CITY
❑ SEEPAGE PIT
JOB NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1'/z% PER MONTH CHARGE AFTER 30 DAYS.
DESCRIPTION OF WORK: ^
CONDITION OF TANK BEFORE SERVICE
_ Good _ Trash & Garbage _ Excessive soap
_ Fair _ Overflowing _ Sand
_ Poor _ Blockage _ Repairs Needed
_ Very Poor _ Odor /�,
Roots _ More frequery servig geeded
�v
TOTAL PUMP
DISPOSAL FEE
r
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TOTAL MATERIALS
DATj. COMPLETED
iyTOTAL
WORK ORDERED BY
AMOUNT
$
No one home ❑ Total amount due ❑ Total billing to
Si6ature for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work