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0102-155 (PLBG)U N Cl) w oCy� — r LU o Z (0H0o C) �a� U) n CO LO N ON U °) a_ Q Z Lo Q O QLU J J co 0< O rn H It Z_ Ob 5 �a J 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 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). ( ) 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. ( ) 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. SITATE FUND (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. Date: 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 per 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) Date BUILDING PERMIT PERMIT# DATE VALUATION LOTTRACT a 02/20120C tr JOB SITE ADDRESS APN OWNER CONTRACTOR/DESIGNER/ENGINEER 46-4 05 CP".O PAY"14.14 94015 CARPMN PD, .INDIT-0` OA 9230 LAQ-CrI TA.' CA 92,25:3 PAUA.0XP,.8XR.';f ("'A 92261 (160)34&27SrJ CSIN 347, USE OF PERMIT Jitirt'3` 4C { hW, X.laMNIMN SYMY F10OK-UP VAIXATION 210000 LW :E;�. rEMA111.11) 48(AITI' 0-91 {:ONSTRUCITION .L,M.d.TIH PLIUMINRITO ME __ M" Wit 101 -0001 -419 -WO SU-IO').`AT, CONIMUCIIION AM P'a: AX Mi $30.00 DUE NOW RECEIPT DATE BY D F ALD 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 Plbg. 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 _ /_ Sewer Connection ��'? Pool Cover 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 COMMENTS: _ Utility Notice (Perm) v I ;. EC SEWER SERVICE, INC. dba ECONO SEWER SERVICES P.O. BOX 192 • PALM DESERT, CA 92261 (760) 346-2793 (760) 328-7760 FAX (760).347-4978 SERVICE CODE I PHONE I TECF t ADDRESS J CITY r JOB NAME AND LOCATION ADDITIONAL WORK NEEDED: JOB MORE ORDER 13258 DATE OF ORDER IICISRV HELPER STARTING DATE TYPE OF WORK ❑ CLEAN DRAINS ❑ OTHER ❑ SEPTIC TANK ❑ GREASE TRAP ❑ SEEPAGE PIT SIZE: PAYMENT TERMS NETiY0.DAYS FROM DATE OF SERVICE 11/2% PER MONTH CHARGE AFTER 30 DAYS. DESCRIPTION OF WORK: / I j , CONDITION 0 TANK BEFORE SERVICE _ Good _ Trash & Garbage _'Excessive soap Fair _ Overflowing _ Sand Poor _ Blockage _ Repairs Needed Very Poor _ Odor _ Roots _ More frequent service needed No one home ❑ Total amount due Tot billing to Signature for above work: or be mailed after I hereby acknowledge the satisfactory completion completion of the above described work. of work TOTAL PUMP DISPOSAL FEE TOTAL LABOR PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TOTAL MATERIALS DAjf COM ETED WORK ORD96 BY TOTAL AMOUNT $ No one home ❑ Total amount due Tot billing to Signature for above work: or be mailed after I hereby acknowledge the satisfactory completion completion of the above described work. of work Y� COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL IE r v, s Nv 082260 I D, Received From: I Date: Address: �o `-} �, �aY,r. e. c..( ,�. c 1� rL _ Cx 1 �� n t"� �... 9S— Account No_,3 0 ) C)Lot(s) Tract Service Address �'y'+�'d G.A. Code ❑ Meter(s) g , ❑ Service(s) ' ❑ Backflow(s) i ❑ House Laterals) ❑ Detector Check(s) ❑ Meter Surcharge i - anitation Capacity Charge i S . U J 1 ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee -Tract - Fee- 0 Plan Check Fees Water / Sewer - i , Tract - ❑ Bond Payment - A.O. - Bond Assmt. ❑ Customer Deposit ❑ Other TOTAL Remarks: L l% �N� P &dopy to: -jLj e Ti C, e ...w.. Cash Water Service /� ~ Check Money i' a Cashler Order 'C&W /-438 (11/89)