04-4049 (PLBG)BUILDINGS'.& SAFETY DEPARTMENT
P. BOx'1504 tk' 760 777-7012
78-495 C `L:4, TAMPICO. FAX (760)777=70 I I
LA :QUINTA, CA•IFORNIA192.253 INSPECTION. REQUESTS (760) 777-7153 .
BUILD.1W3.PERMIT _ R'.•
Application Number `04 0=0'01.04"04=9==B Date 5/11/04
Property Addre•s.s 51260 CALLE PALOMA
APN: 770:173 0-01,;.178. -0000
Application description PLUMBING":-. e
Property Zoning LOW�DENSI_TY RESIDE
-Applica•tion valuation 2925
MAY 1 1 2004
Owner Contractor
----- ---------------=61Y1C IAITA.
HERNANDEZ JUAN L � OWNER t DEPT.
*NOT ON FILE
UNKNOWN CA 9-99,9 9
Permit ,PLUMSING .SEWER
Additional desc
Permit Fee 3,0..00 Pian. Cheek Fee .00
Issue Date •Valuat'lon . . 2925
Qty -Unit Charge Per Extension
BASE, FEE ,:' j0.00
Fee summary Charged :Paid. Credited Due
----- - - - -- ---- - -- - -- - -----.-a'. - - - -- --------
Permit Fee Total. 30..00 00,,. 00 30.00
Plan Check Total 00 .0000 .00
Grand Total 3.0.00.,: 00 V.. ..00 10 ..00
E
P.O. BOX 1504
VOICE (760) 777-7012
78-495 CALLE TAMPICO FAX (760) 777-7011
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: Date:
Applicant:
Applicant's Mailing Address:
Architect or Engineer:
Architect or Engineer's Address:
Lic. No..
BUILDING PERMIT DECLARATIONS
LICENSED CONTRACTOR'S 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 Class License No.
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' state License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
ft applicant to a civil penalty of not more than five hundred dollars ($500).):
dm 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 and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
U' I, as owner of the property, am exclusively contracting with licensed contractors to construct fhe project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
U I am exempt under Sec. t, BA P.C. for this reason
Owner i-t.� Q�f G C, /��Q� �� Z►
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
_ 1 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 and policy number are:
Cartier Policy Number
_ 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 ONE HUNDRED THOUSAND DOLLARS ($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.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this 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 application, the owner, and the applicant, each agrees to, and shall, defend, indemnity and hold harmless the City of La Ouinta, Its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
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 county ordinances and state laws relating to building
construction, and hereby authorize represen tives of this county to enter upon the above-mentioned property for inspection purposes.
Bate ^ rgnature (Applicant or Agent): JEL—a or
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL N? 931-4-9
Received F�r{p.J� Q� v"� =c
Address: +►
�: r'� ` ► '
Date:
bon(b Q
Account No. (s)
Tract
Service Address
G.A. Code
❑ Meter(s)
$
❑ Service(s)
❑ Backflow(s)
❑ House Laterals)
❑ DetectorCheck(s)
❑Me Surcharge
Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn,on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other — --
—
Remarks:
❑Copy to:
Cash
TOTAL $ "
Water Service
[Check
Money Cashier
Order CVWD-438 (11189)
77
. 775
90-384M=2
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 "O.wner/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 perfoimed.by someoneother than yourself, you may protect yourself from possible
liability if that person- applies
for the.properperrritt.in'his. or her name.
Contractors are required by law` t6'belicensed and bonded bythe 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 thaii';your immediate family, and the work (including materials
and other costs). is sh6.,00- or -,more' for the entire project, and such persons are not licensed as contractors or
subcontractors, then'you may an employer.
you,..are an employer, you must register with the State and -Federal Government as an. employer and you are subject
to several obligations .including, Siate. and Federal. income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs'and unemployment compensation contributions.
There may be f nancial:rislts 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 undejederal Law, contact the Internal Revenue Service (and, if
you wish, the U.S.'Small:Business`Admiristration).. Formore specific information about your obligations under State
nt of Ber efit.Payrnents and the Division of Industrial Accidents.
Law, contact the Depa tine
If the structure is intended'for sale; property owners who'are;not licensed' contractors areallowed to perform their
work personally orthrough the i.own'employees, wi hout;a licensed`contractor or subcontractor, only under limited
conditions.
A frequent practice of�unlicensed,persons-professing to be contractors is to secure an "Owner/ Builder" building
permit, .erroneously implying that ihe'property owner is. providing his,orher own labor and material personally.
Building. permits are not required ,to, be 'signed by property owners .unless they are performing 'their own work
personally. `
Information about licensed contractors may be obtained-by:contacting the Contractors' State License Board in your
community or at 1020'N.. Street-, Sail ramen �o; California..95814.
Please complete and return the enclosed owner-builde'r-v cation form so that we can confirm that you are aware of
these matters. The building permit will not be,issued`untilthe verification is returned.
Very truly yours,
CITY OF LA QUINTA ,
DEPT. OF -BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253.
(760)777-7012 -
FAX: (760) 777-7011
OWNER'S SIGNATURE/ DATE.
PROPERTY ADDRESS
04 - 4010
PERMIT NUMBER(s) .
_ AMOUNT
ECSewer Service, Ince JOB TICKET -
dba-ECONOSEWER 'SEkVICE
N*
P.O. Box 591 �8
(760Ya46-.2793,(76p).,-32i-7740,-' Customer order No..
Date omered—
Waste Discharge Fee per1000 Gallons S
Fax.(760) 15173405-6--rd—er TaTen By
Date Pro sea
BILL TO
It
PHONE
ADDRESS
o
TECHNICIAN
CITY
LA A
HELPER
B ADDRESS
SERVICE PUMP SEPTIC TANK HA�,#PTIC TANK BEEN DUO UP? Q_YC3 0 No
I _
ffPMT , :,0)+ S , V T
REQUESTED [3 PUMP SEEPAGE PIT ,ATITS RISER
E3 QFFICE BlLLFN.O
Q PUMP GREASE TRAP.
yellow Cust.
[3 OTHER.•
13Yellow office
QUANT. DESCRIPTION OF
C)610.
Pumping',Fee'per 10004aillo'lis
_ AMOUNT
Waste Discharge Fee per1000 Gallons S
Locating and Opening F&.(1hr.Mfi-.)
Out of Area Fee
GREASETRAPS
RECOMMEND INLET/OUTLET/BAFFLE REPAIR.
EXCESSFVEGREt,SE/FOOD/DEBRIS.
EXCESSIVE ODOR.
RECOMMEND MORE FREQUENTPUMPING.
4
RECOMMENDLINECLEANIWO.
SEPTIC SYSTEMS
0 THE LEACHING SYSTEM HAS FAILED.
0 THERE IS AN OBSTRUCTION UPSTREAM OF THE SEPTIC TAN X.
lt.%vill.b.eiemrsmu.io'cm.nt,aci.a,line eii"i,nscompany.
0 WE RECOMMEND MAINTENANCE PPMPFNG.OF THE SEPTIC TANK EVERY
.[3 YEAR 13 OTHER ,YEAR - 13- 24YEARS'
Tommove built up solids. This;Ai increase im life a6c! ii. M,.
je�c.. t�g syste
[3 THIS PUMP= WELL PROVIDE oNLY..T,Ew,ORARY RELIEF AND NOT
.
SOLVE CUSTOMERS SEPTIC PROBLE M BECAUSE OFTHE AliOVE.'
. .
13 CUSTOMER HAS BE EN . GIVEN Ak "EXPLAWA TibN" PACKET..
A SERVICE CHARGE OFS22MELL, BE DUE.
ON ALL RETRUNED CHECKS,
A FINANCE CHARGE OF I 14%4ER MONTH, 19% PER YEAR, WILL, BE
CHARGED ON PAST DUEACCOUNTS OVER ;0 DAYS.
DRIVERS LIC., STATE
it lbe "Sitisficlory,corripleflan.of the 00e.descrkbe.d work:
hereby acknowledge
SIGNATURE zyF
Total
bur