0108-066 (PLBG)U)
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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.
Licensee
, L#Liic. Class
Exp. Date
C2TI99Q
ahh qq
;%e FnR�rxpJV,, .A.
4 r Signature of Contractor
ev
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).
( ) 1, 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.
" 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 No.
STATE FUND 446-01-90WI
(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
C?�, I shall�fortoWith comply with those prov siI nsi:
9 te: �1 JJ, Applicant—
Warning:
PPlicant _ � "-t'c�
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 hislt
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 18.0 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
ove-mentioned property,for-inspection purposes.
Signature (Owner/Agent) %• Date -e7 ^f .0e l
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01M066 TRACT
(MAWAM, si Si 100
JOB SITE APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
77 "600 rend"?.'LIEF, C004A P. 0. BOX E8
tj: qC)1:6+n-fi, CA 97253 1 FWEEt.'S'.IAM £;PiZ.I X41 CA 92240
C/60)329;6905 C f 0386
USE OF PERMIT
.0,1>11C.A.&f1. iDt;�'td` - SE1le°0.:.CJ'DiFdXf=
VALUATION
t.,50D.00 p s
�'�y �jVy�ys',�eN' kyr ♦prp� /� If )t WX= COST OF CPa?,d"�'e�3:,� DMION
L iiI.LV�i114N.iIY ,FIR �Niu�inLrou ARAr-LUMSPAO 1110 '101-000-419-000 $30.00
1=3 :t;''ft&PAID YMS $0.00
AUG —3 200+°
GI �5QUINiA y�
nNANCE DEPT
RECEIPT DATE" BY ___FDTgE FINALED` INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
l Al- Cenpool,$et-vice, Inc.
P.O. Bog 580188, North Palm Springs, CA 92258
`Since 1959'
(760) 329-6875 Fax (760) 251-3405
State Lie. #265214
www.alcesspool.com
BILL TO
CQ
CITY
_ +!
JOB INVOICE
SERVICE ❑ PUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP? ❑ Yes ❑ No ❑ PMT. ON SITE
REQUESTED ❑ PUMP SEEPAGE PIT AT ITS RISER ❑ OFFICE BILLING
MIANT AMnI INT
'7
Pumping Fee per 1000 Gallons (or fraction)
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee (I hr. Min.)
Out of Area Fee
�
n
i v'"� -a e ®aR
1
Lp Vk h D l
THE LEACHING SYSTEM HAS FAILED.
❑ THERE IS AN OBSTRUCTION "UPSTREAM" OF THE SEPTIC TANK
It will be necessary to contact a line cleaning company.
❑ WE RECOMMEND MAINTENANCE PUMPING OF THE SEPTIC TANK EVERY
❑ YEAR ❑ OTHER YEAR ❑' 2-3 YEARS
. To remove built up solids. This will increase the life of your leaching system.
❑ THIS PUMPING WILL PROVIDE ONLY TEMPORARY RELIEF AND NOT
SOLVE CUSTOMERS SEPTIC PROBLEM BECAUSE OF THE ABOVE.
❑ CUSTOMER HAS BEEN GIVEN AN "EXPLAMATION" PACKET.
A SERVICE CHARGE OF S22 WILL BE DUE
ON ALL RETRUNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR WILL BE
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
IF PAYMENT IS BY CHECK
DRIVERS LIC. N STATE _
1 hereby acknowle a Poe satlActory complet at tate above described work:
SIGNATURE II r
: S -�17-,'
,I,o
Due
�' Al Cesspool Service, Inc.
P.O. Box 580188, North Palm Springs, CA. 92258
`Since 1959'
(760) 329-6875 Fax (760) 251-3405
State Lie. #265214
www.alcesspool.com
TO
i
JOB INVOICE
/_j - I (x -5 nod -e- i
CITY / ('0 HELPER
JOB ADDRESS 7 4 no
l 0 I C� (- o I r ✓V�CI \ Gl //�J t 1� TG.
SERVICE ❑ PUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP? ❑ Yes ❑ No ❑ PMT. ON SITE
REQUESTED ❑ PUMP SEEPAGE PIT AT ITS RISER ❑ OFFICE BILLING
Pumping Fee per 1000 Gallons (or fraction)
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee (I hr. Na)
Out of Area Fee
X-
34! 1A
n
I/J/5a1 n (1 C, ✓�f� Y
THE LEACHING SYSTEM HAS FAILED.
❑ THERE IS AN OBSTRUCTION "UPSTREAM" OF THE SEPTIC TANK-
ANKIt
Itwill be necessary to contact a line cleaning company.
❑ WE RECOMMEND MAINTENANCE PUMPING OF THE SEPTIC TANK EVERY
❑ YEAR ❑ OTHER YEAR ❑ 2-3 YEARS
To remove built up solids. This will increase the life of your leaching system.
❑ THIS PUMPING WILL PROVIDE ONLY TEMPORARY RELIEF AND NOT
SOLVE CUSTOMERS SEPTIC PROBLEM BECAUSE OF THE ABOVE.
❑ CUSTOMER HAS BEEN GIVEN AN "EXPLAWATION" PACKET.
A SERVICE CHARGE OF 822 WILL BE DUE
ON ALL RETRUNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR WILL BE
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
IF PAYMENT IS BY CHECK
DRIVERS LIC.# STATE
I hereby acknowledge the satisfactory completion of the above described work:
SIGNATUREw?^A_ ^ C �I
Total
Due
COACHELLA VALLEY WATER DISTRICT
r.Aqw Pr-r.F:IPT nF:TAii
Received From:(
Date:,
khress: VL
Account No. Lot(s)
Tract
SVce Add 7'
Address
G.A. Code
0 Meter(s)
$
0 Service(s)
0 Backflow(s)
0 House Lateral (s)
0 Detector Check(s)
0 Meter Surcharge
0 Sanitation Capacity Charge
c
0 W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee - Tract -
Fee -
0 Plan Check Fees Water I Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
❑ Other
TOTAL
Remarks.
7.
3 '
0 P y to: ItY
Cash
Water Service
Check
Money
Cashier
Order
CVWD-438 (11/89)