04-3469 (PLBG)La=d_,IDR1 T2004
ci % v..tlY Y qjr Y.7+1'14u.ikQ lii�- .
FINANCE DEPT. BUILDING &•SAFETY DEPARTMENT
Y.0. Box 1504 i �. t (7;60):777-7012
oF 9 78-495. CA:iLE-TAMP1Co31FAX{76.0.) 777=7011
LA QU,IN.TA, CALIFORNIA 922,53 INSPECTION'- REQUESTS (760) 777-7153
'BUILDING PERMIT',
Application Number�4=60346�9>,.. Date 4/14/04
Property Address . . . . :528_0005.AVENIDK-RUB IO
APNc 773-312-016-3 000000 -
Application description': PLUMBING
Property. Zoning COVE''RESIDENTIAL
Application valuation 1'600-'
Owner `. Contractor
JOHNS JOHN V RYS CONSTRUGTI.ON &"DRAIN•SRVC
52805 AVENIDA RUBIO. .,80521 VERANDA LANE
P-0 BOX 107 INDIO CA 92201
LA QUINTA CA 92253• (760 .5.,7.8'-6.40,0.'
(7.60) 564-0122
WCC:. '. NONE```:-
WC: -EXEMPT 05/31/05
CSLB:''' 6'1:0.554 05/3i/05
r CCC : 'B -:C'
Permit PLUMBING SEWER_
Additional desc
Permit Fee 30::,00 Plan, Check Fee .00'
Issue Date Valuation:. . . 1600
Qty Unit•Charge Per Extension
BASE FEE 30.00
Special Notes and Comments ..:
SEWER CONNECT/SEPTIC ABAND.ONEMENT.
Fee summary Charged Paid. Credited Due-.
Permit. Fee .Total_ 3.0.-.00 00 . • .00 30.00
Plan Check Total 00 00 00 00
Grand Total 30-.00- .00 00 30.00
P.O. BOX 1504 ��ca�� VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 4 4INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number:
Applicant:
6O /y 1 n✓3-f1n;ti
Applicant's Mailing Address:
Date: Y - f 3 " cy
Architect or !*ry�ineer:
Architect or ngineer's Address:
Lic. No.:
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S 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 Class} �'V-Cc/3 6 License No. Date Y� ! Contractor_z4- (� , 0646�-
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
the applicant to a civil penalty of not more than rive hundred dollars ($500).):
U 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. , B.& P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
_ I have and will maintain a certificate of consent to self4nsure 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 and policy number are:
Cartier i Policy Number
_ 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
forthwith comply with those provt• s. `n�
Date `� 7 -Applicant `l r
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND, DOLLARS ($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.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name /v
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Ouinta, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
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.
1 certify that I have read this application and state that the above information is cored I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives of this county to antVabove ntioned�roparty for inspection purposes.
Date / Signature (Applicant or Agent): �L��"
n
2502 Morongo Trail
Palm Springs, CA 92264
(760) 327-8859
SOW,TO
SHIPPED TO
STREET
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CITY STATE ZIP
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CUSTOMER ORDER
TERMS
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F.O.B.
Cash' 1J * Water Service�_ �� --
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Order t w ` CVWD-438(11/89)
COACHELLA VALLEY WATER DISTRICT
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' CASH *RECEIPT DETAIL
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Address:
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Account No. i Lots �'
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Tract �
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Service Address �� ' "k' fZL
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G.A: Code
❑ Meter(s)
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$
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ . Detector Check(s)
❑ Meter Surcharge
Sanitation Capacity Charge
' L �'1 �, i 7 0
• °.'❑ W.S.B.F.C.
>' ❑ Temporary Construction Meter
❑ Turn on Charge `
❑' Uncollected Account —Name
❑ Inspection Fee - Tract -
Fee -
. ❑ Plan Check Fees Water I Sewer -
'
Tract -
❑ Bond Payment - A.D. - - Bond
Assmt:
❑ Customer Deposit
❑ Other
TOTAL,
$. 1" • UCJ
Remarks
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to:
Cash' 1J * Water Service�_ �� --
Check a
Money lVl CCiI Cashier
Order t w ` CVWD-438(11/89)