0306-296 (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
Date ;l S/ Signature of Contractor,•,lz, fF t �'� x�t`•t' •—
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 4 `
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.
(A )- 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 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.,- w
Date: '40 , :r Applicant
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.
Signature (Owner/Agent) r�`� ` • �'`;�`- ' Date=
BUILOING. PERMIT PERMIT#
DATE w/ pf y( VALUATION o LOT TRACT
ADDRESS -06'4/ A�, cI in.DA RAg �'t T.2 JOB SITE APN _
OWNER CONTRACTOR / DESIGNER / EN (NEER
F?!.) SAcC, Z.Fm R Y 5 C�D.N 111,1 =0111 & M-)�,f<\� «iCYc%2CC
`5q-06 )ME.NJ ARWJ1RE4. 82154'TATiQ'C<ITY,AN9
USE OF PERMIT
P1 X -MBD -To
X:P'I fC AFIAN.DCXN,-, Sf-WE^R. C010IMN"
VALUATi01J
1a909.Udt ;'nu
MMT&l IM -D tMWf OF V-01TSTRI f.:''(". ON
PRP WT Y%m SUMAMPY
1PLA,IM01146 RE 101.000 4M,000
Ar1D PLW. Smi{cx
IMS r-FE-PAWTITS
'ln,�.'it� 111 IMES 3 0114> 110W
I19(*,( )
U JUN la 2003 U
CITY OF LA QUINTA. .. ,
FINANCE DEPT
RECEIPT DATE BY DA FINALED INSP CTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms 6 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
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 ConnectionEncapsulation
'
Gas Piping
Gas Test
Appliances
-7� !
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:
�w"Fv3l:r�::.a-rs....,.-R+u�,.iwOt
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL dV 0 96302
`. Received From:
/ 'rr
Address:
i
'Account No._�i�� �Cl I �I , 2"� Lot(s) Tract
r Service Address �' L G.A. Code
0 -Meter(s)
O .Service(s)
❑ Backflows)
❑ House Lateral(s)
':,O Detector Check(s)
Meter Surcharge
nSion Capacity Charge e:5
;;❑ emporaryConstruction Meter
' • .O Turn on Charge ..
-".�.p Uncollected Account - Name
b Inspection Fee -.Tract -
'Fee -
`.• O Plan Check Fees Water I Sewer -
Tract
':.. ❑ Bond Payment- A. D'. - Bond
i.: Assort.
i;P Customer Deposit
:❑ Other
TOTAL
Remarks: /� eE✓•
-777
ff <4
Cash /+ �z;r °` WatenService
Check
Money ! s ?a4u
sCashier
Order ,, n, xs •e rkr, CVWD-43B(11199).
9
VALLEY WiDE -PUMPING SERVICE
"Your Waste Is'Our Problem"
it5::JOUAINIVOIICEI-.,'�44
-8575
I UU Q.'Oul 11 lZir vvay - oulLr 1-jj- CUSTOMER'S ORDER NO.
D ORDERED
PALM SPRINGS, CA 92262
(760) 3224400 (760) 347-3545 O=
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0 P.M.:
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BILL T,
PINE
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AD:r.k:2
MEIN
CITY
ly Ad
FIELPER
J0
0 DAY WORK
D 'rSCRIPTION OF WORK
.,0 CONTRACT
0 EXTRA
QUAINT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT
Gallons
Pumping Fee per 1000 gal.
N
Dumping Fee per 1000 gal.
Out of Area Fee
i.
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
z.
MECHANICS @
TOTAL
HELPERS. @
I
LABOR
I hereby acknowledge the satisftory
TOTAL LABOR
cd
completion of the above descrili work:
TAX
SIGNATURE
DATE EOMPLETED
TOTAL-.
To Reorder Call NEBS CUSTOM -printing service TOLL FREE 1-800-888-6327 NESS, Inc., Peterborough, NH 03458.
-Z
Ref. No: G t07O35661*1�.':
NOTICE TO OWNER
Under the California Mechanics Lien. Law any contractor, subcontractor, taborer, 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 agalnst 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.
f
3) After UPON making payment on any completed phase of tge.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.
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