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0303-071 (PLBG)LICENSED CONTRACTOR DECLARATION p'. I hereb� affirm under penalty.of perjury that l 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 04402 �%i % f. Dat 'Z !' A Signature of Contractor �4 v� "f' i i" _. y_. 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 Ct.ARENDC1<1 ?,i`ATK7 Policy No. 61K.R0132`,U14 (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 prov sions� :. Date: I A— Applicant �/% -.• �FiG �•x+.��i< d Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a 'permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property four inspection purposes. Signature (Owner/Agent-✓��`'''�-� Date - BUIL 'vGPERMIT PERMIT# ' DATE VALUATION LOT? TRACT JOB SITE yy ADDRESS�a �S.aI�J.S6tt!i.a'{J•a�°m'e.r; ' APN •.. .• OWNER CONTRACTOR / DESIGNER / EN (NEER iF7iiIJAM YOUNG MOM. UK" VALLEY PLUMP. DIG, . 46790 QUMON ... WAID1 CA 92201 ("m0p47-3629 CT31.6 101 j USE OF PERMIT :��f3�ei��i1•�Cf r T1Ir.ai4?Cid-dI"r'1"rI�TTC Pdks?rtO($ltil�rfe'T L: . PSAR 0 6 1003! �'t'a1,1f M7"IC11�1 f ,011,0.00 1,4' CITY OF LA QUINTA FINANCE DEPT. wism. ) Con" OF cormyRuar1:ON rrimr1° 1i`IFIR GJ�IIy t PLTI➢r?13= FEE SWIM 101!.000,419-000 SM -TOTAL C011 8 rRUCOtION ANT) PLAN CIM -3K $30.00 LEWS lY.f3,S-PAWAMM $0.00 IVEAL PMUT"b'S X3 ]DUE INTOW .-✓'Y RECEIPT DATE /�� % :81%' DATEFINALED INSPECTOR 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 Pibg. 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 O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection _� 03 _ s' Encapsulation as Piping Gas Test Appliances =%go Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole nderground Conduit Rough Wiring ow Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) Final COMMENTS: N COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL Received FrDate: Qmtk) Address: Account No Lot(s) Tract Service Address G.A. Code 0 Meter(s) $ 0 Service(s) 0 Backflow(s) 0 House Lateral(s) 0 Detector Check(s) 0 Meter Surcharge 44 ©--Sanitation capacity Charge 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 Sewer - Tract - 0 Bond Payment A.D. --Bond Assmt. 0 Customer Deposit 0 Other TOTAL t. Remarks: 1901opy"to: Water Service �Z Cash Check Cashier Money Order EC Sewer Inc Servic e r .' JOB TICKET dba ECONO SEWER tiRVIbE P.O. Box 581029, North Palm Springs, CA. 92258 (760) 346-2793 (760) 328-7760 Customer Order No. Date Orders Fax (760) 251-3405 lorder Taken /By Date Ptomis' % Int lr .�'� h ►" -� BILL TO P_HON ADDRESS1 / TECHNICIAN U (Jtt t 1L l� 6Al A - CITY UPI I JOB ADDRESS �- – aZ(.� kcn'�&� J`vCla-ez - /,. , _ .. SERVICE PUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP? Yes ❑ No PMT. ON SITE REQUESTED ❑ PUMP SEEPAGE PIT AT ITS RISER CE BILLING [IPUMP GREASE TRAP O Yellow Cust. [I OTHER ❑ Yellow Office UUANT. DESCRIPTION OF PRICE AMOUNT DOD Pumping Fee per 1000 Gallons (or fraction) / i ,v5 1 GD Waste Discharge Fee per 1000 Gallons Locating and Opening Fee (lhr. Min.) Out of Area Fee Ze A) .3 GREASE TRAPS ❑ RECOMMEND INLET/OUTLET/BAFFLE REPAIR ❑ EXCESSIVE GREASE/FOOD/DEBRIS. ®EXCESSIVE ODOR RECOMMEND MORE FREQUENT PUMPING. ❑ RECOMMEND LINE CLEANING. SEPTIC SYSTEMS " ' - ❑ THE LEACHING SYSTEM HAS FAILED. ❑ THERE IS AN OBSTRUCTION "UPSTREAM" OF T11— 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 "EXPLAINATICM' PACKET. A SERVICE CHARGE OF $22 WILL BE DUE ON ALL RETRUNED 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. N STATE I hereby acknowledge the satisfactory completion of the above described work• • SIGNATURE /� /� /'''��� Total Due ��