0308-193 (PLBG)LICENSED CONTRACTOR DECLARATION
I hc*by 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
731929 C36 ✓ /
Date S9 /,14 • ✓� Signature of Contractor/ /
�
/ _E7,
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 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:
( A), 1 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 1MP1iTT 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 pro�visio�n, s of Section 3700 of the Labor
,Code, I shall forthwith comply withtthosefpr vlslons.
Date: e. _.. �G-,T�APPliceint ��
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 employe
2. Any permit issued as a result of this application becomes null and void
work is not commenced within 180 days from date of issuance of suc
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.,l, 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.
nt) Date
BUILDING:, PERMIT PERMIT p
N
DATE VALUATION LOT TRACT
O;tl�: xii. si,%0.00
JOB SITE
APN
ADDRESS ate -:-i 7oA.IV D�*� oSI i�
OWNER
CONTRACTOR / DESIGNER / EN INEER
MERM., rn-1 JMKI ,
FRFD. YA &9 Piz' BNG
S2.170 AVENMA. RAWFIM
31340 AF,rF_NM , LA GAV:4OTA
LA Q=TA. CA, 92253
CAnIRDRAL %UY CA 9�2y234
11
(7603211-9347 �r ildtt .
USE OF PERMIT
PX:UIt�J'�# j
1
r:ftPTIC ABAWDONMV.NT: A.ND sr.,YLr -Hoo :=UP
'V'ALUATION $,s0o.61' is
EMU= COST OF CONBrIRU'CTIOAN
1152 M f3 '
PLUMBING ING FEL -- S` ER 101.000.419.000 $30.00
CIB-. AL. CO'N1.'1:tt:J17013 AND PLAN CIi1v K
$10,00
USS FRE -PAW 1±W
$0,00
D
Zpp3 TUTAL MKIMT FEES DTJE N0W
UG 15
QV�N'�A
NANC
RECEIPT
DATE
BY
DAT INALE
INSPECT
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
.Shower Pans
O.K for Finish Plaster
Sewer lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
Au —14-03 02: 39P DY5O1V• •& : DY'SON : 760 '771 5820 P.O2
• v.. t,
COACHELLA•VALLEY WATER DISTRICT
a CA$H.9ECEIPT ETAIL ! ,449
(� i •
Received Prom: —�, '—-rn �T I
1 .-
Address:�� ;��..— Dal p••
• Account No.
Service Address ._a.. —. Tract1't?
G.A.,
Metor(s) — — — Goao
D Service(S)_. —. _.T $
U Backflow(s)
H House Lateral(s)
Cl DetoctorCheck(s)
U Meter Surcharge
L >-,TatlonCapacityCharge --- -
U Temporary Construction Meter
U Turn ort Gharge--
F) Uncollected Account - Name
rl Inspection Fee - Tract - — -- : !•
Fee -
I'1 Plan Check F
etas Water r Bower -., '�-* — _ •'+- lY . ;.=�
Tract-
LJ
ract-U Bond Pa Borttl—.
Payment A.P.
r. .
Assinl- i
CuSlomerDeposit—_ -• -�
L' Other
Remarks:
FJCopy to: —• r
Cash .. - .--�,-� ; ':••1: ("::�'!c
Check WatefServh
VALLEY WIDE PUMPING SERVICE JOB INVOICE
"Your Waste Is Our Problem" 8654
l nn C, 0......:.... UU— A.:L.. 1 00
1 UV J. JUI II lJC YYQy JUILU 1 JJ
PALM SPRINGS, CA 92262
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE ORDERED
D 3 —
ORDER T KEN BY J
DATE PROMISED 0 A.M.
0 P.M.
(760) 322-2400 (760) 347-3545
BILL TO /
/` ✓ice / 1�
,`;
PHONE
- Sr
ADDRESIS
ECCIjANI "
CITYj
M ELP
JOB NAME AND LOCATION
r
0 DAY WORK
Dumping Fee per 1000 gal. j
- -
DESCRIPTION OF WORK
f• A�r/ry�l 'J�%
`" / "1 �
' ! ^) Jam,^
�7 �/'' % !/ � J 'c• sem% J � C•
0 CONTRACT
❑EXTRA
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons��U--
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal. j
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
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 @
TOTAL
LABOR
HELPERS @
I hereby acknowledge t�le satisfactory TOTAL LABOR
completion of the ab_ qve described work.,
TAX
SI% TUBE l I
t/ 9 A
DATE COMPLETED
0 3
TOTAL
To Reorder Call NEBS CUST4iM–printing service TOLLFREE 1-900-888-8327 NESS, Inc., Peterborough, NH 03458. i� V
r
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 claim or lien against your property, certain claimants such
as subcontractors or material suppliers are required to provide you with a document entitled
"Preliminary Notice." Original (or prime) 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 family
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 construction this protection may still 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.
n