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0107-133 (PLBG)LICENSED CONTRACTOR DECLARATION Cv hereby affirm under penalty of perjury that I am licensed under provisions of r`apteF 9 (commencing with Section 7000) of Division 3 of the Business and :'ro essionals Code, and my License is in full force and effect. I License # Lic. Class Exp. Date 746139 c-421� Date/Signature of Contractor:' -- i 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. STATE 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 Codej1 shall forthwith comply with those'•pr�wslons. Date: 7 _ J �-.ff= f•�� f Applicant 1 ;dc4 ,. ,•-» . - 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 pro erty for inspection purposes. y Signature (Owner/Agent)'Date e v BUILDING PERMIT PERMIT# DATE VALUATION LOT TRACT JOB SITE ADDRESS APN 46,0,0110TWEL LAW, OWNER CONTRACTOR / DESIGNER / EN (NEER WKIE'.E`7' E k;CONO SFIVMZ .1TE tVI.C)E; 4.-51 O ROYl EL �. -NE 84035 G°AI3P2A')X RAS. 7..NDIO, C.A. 9220] LA QL)f1v E:A CA��11yp!��2 61 P.�pp.��+lj� �17'sCCE:yr t1�'}3' C16QN, Y46-2793 CSX ry 42 342 USE OF PERMIT S'UTIC tx-.Afs",T'oNk42ENT, Ski mE nt;1J:)K.up ; VAIXA110N 1Z 1111`7. ,".93RM°. :O 4:Oe'vyY,' 01? CQ 13,110T ' 211.501W ••��yyyyryryqq�``pp•pp�,, ��`¢g p, �y'�^; A Qt Q g,� y:E� Q4J�YXC�41.4DdiZ � �•�' .S.EeAtti.1::AA�•.�7AfriTf. .,, FLUMB11103'EE_.SEWER IW -000.4.19.000 930.0 �fw t 111j . 1 i� 'J U L 17- 1=9�1 CITY OF LA OUINTA W,T.TT 77pa�,�Cqq q y�yry'1�'1t qt .VJS,�7!Vd ,I.9 Ri,Ga•.l k763.t.y °.L.:�a.SAu� y�Cp)i $0.00 RECEIPT DATE''" t1`7 BY/ -it�ls DATE FINALED INSPECTOR ( C , INSPECTION 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 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 Sewer Lateral Sewer Connection Zig �G 0. K. for Finish Plaster Pool Cover Encapsulation Gas Piping Gas Test Appliances Final Final ..D_/O_J_ D `� 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: , EC SEWER SERVICE, INC. dba ECONO SEWER SERVICES P.O. BOX 192 • PALM DESERT, CA 92261 17m 'AAA -9702 f7arn 29A-77an JO NONE ORDER .1 14903 PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1/2% PER MONTH CHARGE AFTER 30 DAYS. DESCRIPTIO F WORK: _ - CONDITION OF TANK BEFORE SERVICE _ Good _ Trash & Garbage _ Excessive soap _fair - _ Overflowing _ Sand Poor _ Blockage _ Repairs Needed Very Poor _ Odor Roots _ More frequent service needed 7. FAX (760) 347-4978 DATE OF ORDER SERVICE CODE PHONE I TECICI N HELPER STARTING DATE / r 4 7 p BILL TO DA�COMPLETE D WORK TYPE OF WORK ❑ CLEAN DRAINS ❑ OTHER 2-SIrp-TIC TANK ❑•GREASE TRAP 2- EPAGE PIT ADDRESS $ CITY JOB NAME AND CATION ADDITIONAL WORK NEEDED: TANK SIZE: PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1/2% PER MONTH CHARGE AFTER 30 DAYS. DESCRIPTIO F WORK: _ - CONDITION OF TANK BEFORE SERVICE _ Good _ Trash & Garbage _ Excessive soap _fair - _ Overflowing _ Sand Poor _ Blockage _ Repairs Needed Very Poor _ Odor Roots _ More frequent service needed 7. ❑ No one home ❑ Total amount due ❑'Total 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 DA�COMPLETE D WORK ORDERED BY TOTAL AMOUNT $ ❑ No one home ❑ Total amount due ❑'Total billing to Signature for above work: or be mailed after I hereby acknowledge the satisfactory completion completion of the above described work. of work COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL "n 0845-29 . Cashier CVWD-438(11189) Construction Received From.'e'A) Address: -No. 450 -7 -'4 1, Lot(s) Account Service Address 2"' Review. ready for corrections/issue y. o meter(s) Electrical 0 service(s) 0 Backtlow(s) C3 House Lateral(s) C3 Detector Check(s) Cr 0 Meter Surcharge Grant Deed Ig -Sanitation Capacity Charge Plans picked up o W.S.B.F.C. 0 Temporary Construction Meter E) Turn on Charge 0 Uncollected Account -Name 0 Inspection Fee -Tract - Fee - IN HOUSE:- 0 Plan Check Fees Water 1 Sewer - Review, ready for corrections/issue Tract - Developer Impact Fee t. - 0 Bond Payment - A.D. -_ Bond Assmt. o customer Deposit 0 Other '01 Remarks: -C 0 copy to L'_ — q-01 G.A. Code Cq TOTAL $ Water Service IL�� Cash Check M M oney Order Flood plain plan Plans resubmitted Cashier CVWD-438(11189) Construction Mechanical Grading plan 2"' Review. ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up H.O.A. Approval Plans resubmitted Grading IN HOUSE:- Review, ready for corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P, Pub. NN'ks. Appr Date of permit issue School Fees TotalPermitFees I