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0305-109 (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 917,496 09/30/12( 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). (�j) 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 l • i P i 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 EXEMPT 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. Dom;,/�ir APPlicant .-; • � / ; ;?; '%r +`G•i1� '� �-� 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, 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 the above-mentioned property for inspection purposes. r• Sig ature (Owner/Agent) /�*1 Date -- I RUILDIN PERMIT PERMIT # DATE =Ef. VALUATION LOT �'`'' 05/12= swo TRACT JOB SITE APN ADDRESS 51-120AV.F_K1 .A.,PAMEWEZ OWNER CONTRACTOR / DESIGNER / EN (NEER MIC UES & JUAkd A.ROrYR1GTJEZ B D CONMiJi:`:7I014 SEERV'iC.SS 51.120 AWNID A RAND FZ PO BOX 26(Y7 L,A QUINTI.A CA 92253 P.AUA DF._EtT CA 92260 C/60)275-9713 C'BLO 4610 USE OF PERMIT s PzUl"Na SEPTIC A8A•14i70N;-,SZW9R NOOK -'UP vAVJAT1ON 1,50.00 LS Eff .WATM) COSI' OF COP1'FrRUC'DON :PMUr Tim SUMMARY P1.t MI)iNO FEE - SEWER 101-000.419.000 $30:00 S'TIA-1170TAT. ON' AND PLAN CBECK �3U.00 D a LESS PRF --PAID F.&S 3L►,t30 2001cy .. r 7",S DUE NOW_ MAY 12 CITY OF LA QUINTA FINANCE DEPT. RECEIPT DATE 1"`j- '' ;3 BY 1'/ DAT INALED �.� � / . � INSPECTO .. 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 Bond Beam Approval to Cover Equipment Location Underground Electric Underground Pibg. Test Final I 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 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 (Perm) COMMENTS: COACHELLA VALLEY WATER DISTRICT CASH faECEIPT DETAIL 0-95209 Received From: f i " {, -Date .%�-• Address: - / �[J r (al`c iC /.moi'!}`�; ;; Address: Account No. ot(s) Tract Service Address I Ae.'� i . z /�. ,� i.(: n ±,:J2f.�.� c/ .. �' G.A: Code ❑ Meter(s) .Y $ i ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s) ❑ Detector Check(s) ' ❑ Meter Surcharge sanitation Capacity Char 1 U}"_ P Y e 9. r 11161.7) el ; )�../)>'C i'l No. ❑ W.S.B.F.C. � / ❑ Temporary Construction Meter O Turn on Charge ❑ Uncollected Account - Name ❑ InspectiowFee- Tract-- ract.-Fee- Fee- 0 ❑ Plan Check Fees Water / Sewer - i Tract - j ❑ Bond Payment - A.D. 7 -Bond Assmt. ❑ Customer Deposit • ❑ .Other ; jj TOTAL $ ' Remarks:. ;�J ./"/ , J' i.2.J wCopy to: r ,. Cash l Water Service C,10z Check Money Cashier Order CVWD-438(11lrr?) . i 100 S. Sunrise VVay., OUILe 1,33 CUS -R S.ORDER NO: NALLETWIDEPUMPING SERVICE,-:. SERVICE::.PW 'IN VOICELZ"- • "Your Waste Is Our Problem", - 09 0 2 3 (766p224400' (760) 347-35451. ORDER TAKEN BY, , DATE PROMISED 0 A.M. Pumping Fe4per1000 gal. ❑ P.M. B 0 PHONE ADORE S 100 S. Sunrise VVay., OUILe 1,33 CUS -R S.ORDER NO: DATE ORDERED , PALM SPRINGS,-Q��-92262: Gallons (766p224400' (760) 347-35451. ORDER TAKEN BY, , DATE PROMISED 0 A.M. Pumping Fe4per1000 gal. ❑ P.M. B 0 PHONE ADORE S Z. Dumping Fee per'1000 gal. e6— TiELPER 76. %-2 JOB NAME A1qD LOCATION 0 DAY WORK DESCRIPTION OF WORK, 0 CONTRACT . /0 EXT FLA - Locating Opening Fee (per hour) QUANT. DESCRIPTION OF'MATERIAL USED PRICE AMOUNT Gallons 40 Pumping Fe4per1000 gal. Z. Dumping Fee per'1000 gal. Out of Area Fee Locating Opening Fee (per hour) Size System: A fd 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 @ HELPERS @ TOTAL LABOR I hereby acknowledge the satisfactory describede completion of the above :cir�,taecd work:TpX TOTAL LABOR SIGNATURE DATE COMPLETED TOTAL To Reorder call NEBS CUSTOM -printing service TOLL FREE 1-b60-968-627'NgBS. Inc., Peterborough, NH 03458. Ret. 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