0306-386 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions isfi
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 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 un�er Section � , B&P.C.=fo ,this reason f
Date ? V, 0Signature of Owner / 3
77
WORKER'S COMPENSATION DECL RATION:-^ '� H
I herebyiaffirmjunder penalty of perjury one ofl� 'e following declarations:
() I have and will maintain a certificate of consent toself-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).
Q , I certify that in the performance of the work for which this permitAs issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Califor 'a, and agree that if I should become
subject to the vyorkers' compensation provisions of Section 3700,6f the Labor
Code, I shall forthwith comply with th Provisions. %
Date: �6.. /-1-I IfApplicant �a` �lw.'r';. I
my r t. w,� y, av ' j l ,w, ✓'�+*«...-✓..
3.1 F
Warning: Failure,to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil finesrup to $100,000, in
addition to the cost of compensation,rdamages as providedfor in Section 3706
of the Labor Code, interest and attor6ey's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of nLa Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject „permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State lawa`i�relating to the building
construction, and hereby aut`o�ize representatives of this City to enter upon
the;above-mentioned property for inspection purposes.f
Signature (Owner/Agent)? A,, J -Date -4
` 'f, BUILDING PERMIT PERMIT
DATE VALUATION :;, •:'t LOT TRACT
r'-4,i7t3Ef (Df; 03b e, 3$C0
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER�
IJAW i`tAN7-GS0 •J
0 ••.FFA iVIL BITTLDER
U. Q''KWIVA CA 1). Z3
E 3 C`Ei �al�
USE OF PERMIT �t
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jesmu ca,;r or cc $1r . rk ur xcv
4j1iOtT,E'16T
.T'E?<2.mn FEE 901lflAUNY
PLUMBINOY"_--S3= ,rHR 101.190-439-ta O
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$:30.00
JUN 2 4 2003
' 031.x' TNla'rrt...1, I idCYWV'
CIFOr. LA A
INANCE DEPT
S.ity.lil,
RECEIPT
DATE - / �' r
BY _
DATE FINALED
INSPECTOR
W
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
,qond Beam
Approval to Cover
i"
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` G i
-=
Appliances
i0
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Lnderground Conduit
Rough Wiring
Low Nottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
6��5—ec'
S v O
05 0 ,316
COACHELLA VALLEY WATER DISTRICT
.CASH RECEIPT DETAIL f;tr fN? 96131
Received From: 77/—
Address: 6
) �c - - - ,
Account No. j Lot(.) Tract
A- Ail &11 1-, T_� f..-,
Service Address -..I
0 Meter(s)
0 Service(s)
0 Backflow(s)
0 House Lateral(s)
El Detector Check(s)
•O Meter Surcharge
W/9'anitation Capacity Charge 10 vir A/ -Z- f LJA M Q N
0 W.S.B.F.C.
0 temporary Construction Meter
0 Turn.on Charge
0 yncollectedAccou.nt- Name
0 Inspection Fee - Tract -
Fee -
• Plan Check Fees Water Sewer -
Tract -
• Bond Payment - A.D. -
-Bond
Assmt.
❑ Custoryler Deposit
0 Other
TOTAL
Remarks:
14,106, to:
12"i
pas/!Z.
UZI-) C2 L0,1\J1
'Cash
Water Service
Money
Order
U,
a
Cashle
CVWD-438 (11/89)
/I
VALLEY WIDE PUMPING SERVICE JOB INVOICE
"Your Waste Is Our Problem"
8591
1 KA O IA I.... Q...:a.. 1 99'_
100 J. JUI If IJC YYQy JUILC 10J —�
PALM SPRINGS, CA 92262
(760) 322-2400 (760) 347-3545
CUSZOMER'S ORDER NO.
1, /
DATE ORDERED
- �
ORDER TAKEN BY
ATE PROMISED ❑ A.M.
D P.M.
BILL f `t
PHONE
l
AdBR S
XEAPlc
JOB YVAME` ND LOCATION
❑ DAY WORK
O CONTRACT
DESCRIPTION OF WORK ''
D / O.
❑ EXTRA
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
/
Gallons
Pumping Fee per 1000'a 1.
Dumping Fee per iioo0 gal
Out of Area Fee.
Locating / Opening Fee (per hour)
Size System: /
i
A SERVICE CHARGE OF $20 WILL BE DUE.
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR
WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR _
AMOUNT
TOTAL
MATERIALS
MECHANICS Q
TOTAL'
LABOR
HELPERS C�.-`''
I hereby acknowledge the satisfactory TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE
DATE COMPLETED
TOTAL
--
To Reorder Call NEBS CUSTGM-printing service TOLL FREE 14M-888-6327 NEBS, Inc., Peterborough, NH 03458. Ref. No: G 710703566
NOTICE TO OWNER
Under the California Mechanics Lien Law any contractor, subcontractor, laborer, supplier
or,other person who helps to Improve your property, but is not paid for his/her work or
supplies, has a right to enforce a claim against your property. This means that after a court
hearing, your property could be sold by a court officer and the proceeds of the sale used to"
satisfy the indebtedness. This can happen even if you have paid your contractor In full If the
subcontractors, laborers or suppliers remain unpaid.
To preserve their right to file a clalm.or.1len-against your property, certain claimants such
as subcontractors or material suppliers are regtljred to provide you with a document entitled
"Preliminary Notice." Originat4or piltne) contractors and laborers for wages do not have to'
provide this notice. A Preliminary',Notice is not a, lien against your property. its purpose is to
notify you of persons who may have a right to file a lien against your property If they are not
paid. Generally, the maximum time allowed for filing a claim or lien against your property Is
ninety (90) Days after completion of your project.
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY,
YOU MAY WISH TO TAKE ONE OR MORE OF THE FOLLOWING STEPS:
1) Require that payments be made directly to subcontractors and material suppliers through
a joint control. Any joint control agreement should Include the addendum approved by the
Registrar of Contractors.
2) Issue joint checks for payment, made out to both your contractor and subcontractors or
material suppliers involved in the project. This will help to insure that all persons due payment
are actually paid.
3) After UPON making payment on any completed phase of the project, and before making
any further payments, require.your contractor to provide you with unconditional lien releases
signed by each material' supplier, subcontractor and laborer involved in that portion of the
work for which payment was made. On projects Involving improvements to a single f9miiy"
residence or a duplex owned by individuals, the. persons signing these releases lose the right
to file a claim -against your property. In other. types of consirgction this protection may stili be
Important, but may not be as complete. TO' PROTECT YOURSELF UNDER THIS OPTION YOU
MUST BE CERTAIN THAT ALL MATERIAL SUPPLIERS. SUBCONTRACTORS OR LABORERS
HAVE SIGNED.
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 variuus 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 State
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
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 1A QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) Zrn-- 012
777-7011
IGNATURE/D TE
yN
ADDRESS
3 ktt"->
PERMIT NUMBER(s)