0105-114 (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 ' 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).
(#o'ram exempt. under Section , B&P.C. for,thls'r9ason% A
Date ,.D .f1�t�e� 1 Signature of Owners ; 111
�'�.�➢.
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.
(This section need not be completed if the permit valuation is for $100.00 or less).
(u .'f 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,' 700 of the Labor
�r
Code; l shall forthwith comply with those provisions..
�D e. Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up 4o $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 forrinspection purposes. r
13nature (Owner/Agent); f' L �' �� -Date -
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
46 301 ROADRUNNERIN
USE OF PERMIT
�'l�oo��.gr•��tfeyy��.ipgp•�
i q� yPapr �p ���,yy+�7 ,p� l �pP �+yp�
u�•64GF�49.6✓.P1:I./�FV fJIw1�4�t.TA l�iX76 T.Y.:VIV'y�'f;N.e�. 4r��1'�A'A.s'tl f.W�
.
VAX,A:T,, TICIBd •' t,Uii ,Cil L
1,MAM
F TRAW kr%Zi IYUM.I�ARY
PLUN581140 RZ... SP�' 1911 20 AR1C bs��jt7C3 $ D,1►i►
7MV M"'.G'AW l.•� EX
4r a n
MAY -- 8 2001 : I FNES DUE HOW
• CITY OF LA OUINTA /
FINANCE
!"
DEPT /
RECEIPT
DATE j
r
DATE FINALED
INSPECTOR
T '
a INSPECTIQN _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
POOLS - SPAS
BLOCKWALL APPROVALS
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 _
Sewer Lateral o Q�
O.K. for Finish Plaster
Pool Cover
_
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final 15J
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)
COACHELIA VkLLEy WATER DISTRICT
-
Tract
G.A. Code
TOTAL $
cE II
'�' .S
Remarks:
k7Copy to:
v✓
Cash
Check
w
Money
Order
-
.Nr
-Re
- ,'. r ' � ' �•r �' 9,+i �' s � .y� ; ��,s�+. T� �� "ay`d'Yiwr'a'YM�`�C �..
r k�
t-
•
+" 7� ..:. 3`,.y' ',r,.,� .rte Ai�d„'^n .fir ..?" �.Y.-'' k773l .n "✓ r
Water Service
Cashier
CVWD-438 (11189)
ROCS ivad 0.T-25-2000 II:4gam Fram-+76p3983ii1 To-CVVID PO SATELLITE Page 017 1
A-1 Cesspool Service, Inc.
-ti
P.O.B9>r'88,Nort,.)PaUnSprings, CA92253 JOB INVOICE
Since 1959 •"`^ ':
(760) 329-6875 Fax (760) 251-3405
State Lic. #265214 Customer Order No Date or ere F
www.alcesspool.com j11,ki I,
BILL TO ? HON
ADDRESS TECHNICIAN
L-(-,. I
f
. JOB ADDRESS
l--fi�k�8P3E1r3r��.:`r'r� `>�;�.•il=:t�R i+
SERVICE b' PUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP? ❑ Yes ❑ No =❑ PMT. ON SITE
REQUESTED ❑' PUMP SEEPAGE PIT AT ITS RISER `❑,OFFICE BILLING
r)1 ]ANT nFSCRIPTinN PRICF AMMINT
1000 0
Pumping Fee per 1000 Gallons (or fraction)
Waste Discharge Fee per 1000 Gallons
/
Locating and Opening Fee (Hr. Min.)
Out of Area Fee
c
r i
� t1
�� ;
TECHNICIAN REMARKS/COMMENTS:
n
V i
A SERVICE CHARGE OF $22 WELL BE DUE
ON ALL RETURNED CHECKS
A FINANCE CHARGE OF 1 112% PER MONTH, 18% PER YEAR, WILL BE
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
IF PAYMENT IS BY CHECK
DRIVERS LIC.0 ! STATE
.. ,
I hereby,ocknowledge the satisfactory completion of the above described work:
SIGNATUREC`I (- /
Total
Due
J
^ S,L^.�
�5
NOVICE TO OWNER
Under the California Mechanics Lien Law any contractor, subcontractor,
laborer, st.pplier, or other person who helps to improve your property,
but is not paid for his/her work or 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 subcontractor or material suppliers are
required to provide you with a document entitled "Preliminary 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
the 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 insure that all persons due payment are actually made.
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
suppliers, 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 be as complete. TO PROTECT
YOURSELF UNDER THIS OPTION YOU MUST BE CERTAIN THAT ALL
MATERIAL SUPPLIERS, SUBCONTRACTORS OR LABORERS HAVE
SIGNED.
.r�C.+��t�r.�'+....C�"'"�L''""t �r.y'��'�iSrt" �+'�:tj "`���'��?+'t+•�w',��.D,�yS IFS
�."7 . .
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be.aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work.If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to. have a business license
from the 'City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to-do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the irk (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an emphyer•and you are subject
to several obligations including State and Federal income tax withholding, federal social .security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under Stare
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are s.11owed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Olivner/Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are perrorming their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' St.te License Board in your. :
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF. BUILDING AND. SAFETY-
78-495
AFETY 78-495 Calle Tampico
La Quinta, CA 92253
(760)777=7012.:
FAX: (760777-7011
OWNER'S SIGNATURE/DATE
_Z4
PROPERTY ADDRESS
PERMIT NUMBER(s) ' �/