9901-070 (PLBG)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
740159 C;42 e° wfto
VDate /� ' [ ` / 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
( ) 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 under Section B&P.C. for this reason
Date Signature of Owner
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.
1 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;
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- provisions.
r
t �Date:,l.. ,•d ref, Applicant'. ft,i.-:'�. --.•...�
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
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'
the above-mentioned property for inspection purposes.
%Sig ature (Owner/Agent), Date.' �r
BUILDING PERMIT PERMIT#
99€i.t-f97t3
DATEVALUATION LOT TRACT
f - : ` q' , 500.00 A
JOB SITE - -
ADDRESS 53-455AV +'NWA RURIG
APN
774-11'2-017
OWNER
CONTRACTOR / DESIGNER / ENGINEER
r3r1,rNnrr�l1T I Ef+la'rIt' A
.f 6.v Ui.�J'�JUIr 1�1 ;iii ./U:.TK"%
r; �AI^fj'VAIIre[) CSF±FL1rrr,r,,
}i NL" 1 M Yi l.It, l�1�•'i {.4.•1.
536-55 fl.VE 1 DA RUBI A
84035 <.,1VBA7a. N PQ MD10,R CA 92.201
LA QXTUNITA. CA 92253
PAJAMl)MM' LA .92261
(760)345-273
USE OF PERMIT
PLUMBING
Et' TIC .ABANDON. Std V AER CONTIEC T (LO 14 0D PROFECT 49841,0)
cOmmlcr tiMOU111irr.1,5010,00 LS
' It,OA"AN _A TCID C0^c,4T 01FT /`�1'}�iC*.•V'9C98 PA""TYt►14F
.9L.':l A 1. i � �{ i/+,1' & V15. '4 1 {;Y A L\Yl'L,. A 16ttW
•6 Gfll:k Adl..
6.g..�i4jl•?9tJ '
RERM11WE SUMMARV
1'LILI !'131:[ G FEE -- SMR, X 01 •-IN0 419 -OW M.00
a
- .. ._ . � eU��?rt,�l'a'�i� ��3��'i�RI.,��I'[t��i ��N��.P�.•�f� fi'�'��'�, _
- - - ���y,���
LASS k'i 3 .l�A.1 FEES
.0.9�
TOTAL P EAN11T FEVS, 1_01.E NOW
S30.040
RECEIPT
DATE
/Ij.2
BY V
DATE FINALED
INSPECTOR
a
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. a
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 Piaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) 2, —t. —
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 (Perm)
COMMENTS:
.
P,FCON0 SEWER SERVICES
`P.O. BOX 192
PALM DESERT, CA 92261
JOB WORK (00 -PER
26 8 ?4
Ut5UHIPTION OF WORK S -PAYMENT TERMS NET 1U UAYb fKUM UAI[ Vr JCKVILn
11/2% PER MONTH CHARGE AFTER 30 DAYS.
M
• - _ - _ _ -
TOTAL MATERIALS
DATE OF ORDER
TOTALLABOR
FAX -(760) 347-4978
P1 E ASE PAY FROM THIS INVOICE.
CUSTOMER'S ORDER NO.
PHONE
EC A
H LPER
StARtINC41DAE
BILL TO
$
o one home ❑
ORDER TAKEN BY
ADDRESS.
❑ DAY WORK
!E]CONTRACT
CITY
❑ EXTRA
JOB
LOCATION
JAMEAD
o� L
r�
( !2 - D
JOBPHONE
Ut5UHIPTION OF WORK S -PAYMENT TERMS NET 1U UAYb fKUM UAI[ Vr JCKVILn
11/2% PER MONTH CHARGE AFTER 30 DAYS.
M
• - _ - _ _ -
TOTAL MATERIALS
TOTALLABOR
P1 E ASE PAY FROM THIS INVOICE.
NO STAIFMFNT WILL RE MAILED. •
TAX
DATE COMPLETED. WORK ORDERED BY
TOTAL AMOUNT
$
o one home ❑
Total amount due ❑ Total billing to
Signaturer
for above work: or be mailed after
�- completion
I hereby acknowledge the satisfactory completion of work
`, of the above described work.
CSesvet- Suvice,.MF;dba
Econo wei- Service
PO Box 192
Palm Desert, CA 92261
(760) 346-2793 or 328-7760
Fax (760) 347-4978 License C-42 #746159
Date: 3 -.L-"/
RE': City of La QUinta
Project M-20
Sewer Connection
4
the owner of property at
L t6&2 Address)
Print Name)
in the City of La Quinta,. release Econo Sewer Service of responsibility for restoring ffiY�hy to
",0iopa
to it's original state prior to the sewer connection. . Please note the following areas they are
released from:
3.
4.
Sna ue of con, EcoiTo �e4—wer)e9rvic Employee qS�inaature nature 'roperty
Econo Vier