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0304-259 (PLBG)U) F- 04 W O =) M r- d u7 r W o Z co O_ FZ P J U� �aW to Z O N, Q Z Lf) Hlr 0 X W �= mUU O a rn Z oo J 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 Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date Date Signature of Contractor ,OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I ani 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). ( ),JI am exempt under Section , B&P.C. for this reason 'Date Signature of Owner .4- r-�,-,r4, ",(" "_,,' * 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 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, X`Stiall 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 Coale`, I shall forthwith comply with those provisions. ,Z , ,,,Dat,-- Applicant — =° '' l 'r•"tom fZir 1�^ � 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 Gr 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 thelabove-mentioned property for inspection purposes. Signature (Owner/Agent) Date t' ?'PERMIT# {- PERMITUL t,-,DING DATE VALUATION LOT, -�� TRACT_ JOB SITE ADDRESS.52-=.A"�l�t�'IV A 4i Ale. t?�NZA APN . . OWNER CONTRACTOR DESIGNER FNINFER yrmo N.nPAmyi JYWIC 7VLLDI 52.8 40 AVENWA Caf RRAKA. I,AQUINTA. i, CA 922521-1 .. t) (MIX, . USE OF PERMIT i y ShWX Of:9HAdEC`1'ISEP7YC A8A-9]DQ V1,,IVI9WT VAT.lDA'l 10W 11000100 L9 lALI PIMT.M SWIY.LdT&,IIARY 1�Y,��3MfllkiC� FAL -- SI~:�1�� }. �)} •G1J{?*�93 S�•{}�1b �.30,itU ' D 11��3 G� F NPNG 3'OTAL COMMV'UCTION AND PLAN C VCK 00.00 L S PTeCis-1�A�iJ :�+: Y13 $0,00 t , RECEIPT DATE +7 BY DAT NALED 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 OX 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 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 :.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 (Pert) Remarks: ( s C' ./ 11.. i t �` i �•. j C: f i t Copy to: Cash Check > Money !x Order drawing of record.. 9 95038 s L /7 ' Date: le Tract SC — TOTAL $ Water Service n Cashier, i CVWD-438 (11189) These deviations from the drawings of record are beyond the control of CV)A7D; therefore, the district will not be responsible for any charges incurred by the homeowner as a result of these inaccuracies. July I, 2002 COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL Received From: �...> �., l7 A At M ALIA (� C—c Ai S 4 ?�I-E Address: J/G�. 'A f4 f\1.1 ` P,�i �.. �* Cf`1 �'rt A; Z.%+ z-,/ ' 1 6 �. •jg �n;� r'LK. Account No. L 'G7�_Z r � Lot(s) AA Service Address c;7.-- ? Q AV -2 AL% :^6.12.22,1 A ❑ Meter(s) ❑ Service(s) ❑ Backflow(s) O' House Lateral(s) ❑ DetectorCheck(s) _7 ��M✓✓e''tt"prSurcharge l -Sanitation Capacity Charge AJ Nlr_i P1f(-1 .• tr A /.1 ' ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee - Tract - Fee - ❑ Plan Check Fees Water / Sewer - Tract - ❑ Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit ❑ Other Remarks: ( s C' ./ 11.. i t �` i �•. j C: f i t Copy to: Cash Check > Money !x Order drawing of record.. 9 95038 s L /7 ' Date: le Tract SC — TOTAL $ Water Service n Cashier, i CVWD-438 (11189) These deviations from the drawings of record are beyond the control of CV)A7D; therefore, the district will not be responsible for any charges incurred by the homeowner as a result of these inaccuracies. July I, 2002 BUDDY'S SEPTIC- SERVICE 67405 PE11 ETA RD CATHEDRAL CITY, CA 92234 CUSTOMER'S ORDER NO. 2 -71 LZ z- DATE a LA4j(!? NAME ADDRESS CITY, STATE, ZIP SOLD BY CASH C.O.D. CHARGE ON ACCT. MDSE RETD PAID OUT QUANTITY DESCRIPTION PRICE AMOUNT 1 2 c- 3 3 ➢` ��5'�onL 4 5 6 7 8 9 10 11 12 131 k / ZCo u G� 14 15 16j i 17 vv - 18 19 20 RECEIVED BY al�aftw KEEP THIS SLIP FOR REFERENCE 5805 0 OWNER/BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the State and Federal Government as an employer and you are subject to several obligations including State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There may. be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under Stare Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your T community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, CA 92253 (760) 777-7012 FAX: (760) 777-7011 sz e4 V-01-03 OWNER'S SIGNATURE/ DATE 52 No 6a7yakl Lq PROPERTY ADDRESS 0�o � �! PERMIT NUMBER(s)