0307-124 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Fes— 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 License # Lic. Class Exp. Date
LO
482180 C21 C:42 11/30/20
oZ k_ Date ' , Signature of Contractor '
co Q
JF
�, OWNER -BUILDER DECLARATION
HLU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
I)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).
ce) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
rn
Ez z WORKER'S COMPENSATION DECLARATION
'It CD Cr I hereby affirm under penalty of perjury one of the following declarations:
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
Om _ Q performance of the work for which this permit is issued.
Q U. () I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
oo Z Carrier COAiB.INFZi OpSMAI. Policy No. 05.000100
�p
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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: 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, indemnity
& 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
• i 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
i
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) /% Date
BUILDING PERMIT PERMIT# ��_1
DATE VALUATION LOT 24 TRACT
JOB SITE ` APN
ADDRESS 5_24o Awn
xi/i w m
OWNER CONTRACTOR/DESIGNER/EN (NEER
PATRICIAJONES ALAM UMER.GROUM) CONN.
53-240 Ate, t ACARRA'LK 318703 VISTADME.
I.A+QUIM�A CA 92253 C.A 92234
(76U)324-1911 rmI'.6 769
USE OF PERMIT
SEPTIC A1i.P.A+SDON; 5nVZi: HOOK -Op
V.ALUA` 1014
2,000.00 ).,0
3?;!rTI COST 4F CONS1RaVU110N2^10MPLUMBING FEE - SEWER 101.000-419.000 g34.tM
9M -TOTAL C'AM I -LAW CWS $30,00
D D I -E.93 :�'R.E•PAW M � $0,00'IC% 1T'1E 3? S Dom: NC7'U� MOOJUL 10 2003.
CITY OF LA QUINTd1
FINANCE DEPT.
RECEIPT DATE BY DATE FINALED INSPECTO
_r I -- 1 Q-
•
CD
COACH ELLAVALLEY WATER OISTRICT�
r
O
@ i .
CASH RECFIPT.DECAIL
96
R=ce i v ed From:Accou,
�4
A CJ zf% ' "'Y i �- ��/Y V Lots�i
•
Tract `, 7 r�S�' tv' �.' = �-t. �. C.f .;,•may
{
Serrice Address -7 - .rF�
j'}
G.A .ode
is
Me',er(s)
C Sackfln,'t(s)
D HouseLateral(s) _
I
Cl DeOeCtOrCheck(s)
i"
;teterSurcharge
.—.
�
+
i
;
i7f-Sanita?ic6CapaciP/Charge
ter `' -
f' f j =
I
x
u Tern pararyConstructionMate r
i
G Turrr on Charge
t
C UncaiSectedAccount -Name
:_7 Inspection Fee- Tract-
_
Fee -
i
G Plar, ChecR Fees WaterfSewer-
�
Tract =
Ej Bond Payment - A.D. - Scnd
Assmt
J c Qstomer Cepcslt
G 0!her
TOTAL S `
Q
co
ocopy to:
CD
Cashier -
I'COv•i '-T'.
- ...�_...
.:....-..-�-r- -- .r-,..-ev._..'_-_ _ - .. _ w.,•:----r--w�
._.-....... _. _.s -
--."...-
� •--._�... -- .s,.......>.s-. .i .........---�--...�-•
I�
C\J
'
. I
SANCO (
PUMPING SERVICE - 2502 Morongo Trail
J -
Palm Springs, CA 92264
(760) 327-8859
612239
SOLD'TO / ! /
SHIPPED TO,
STREET? ,�-� �' l"
STREET v
F.A.B.
CITY STATE ZIP
CITY STATE ZIP
CUSTOMER ORDER
SALESMAN
TERMS
F.A.B.
TE 1
"DA"2
/
,/)-E>Z
`-3S
1..
1
1
1
1
1
PAYMENT DUE UPON RECEIPT .