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04-4666 (PLBG)t auk& BUILDING & SAFETY DEPARTMENT � UU4 P.o�11PDX 1504 (760).777-7012 F►tpF4.-71-495 CALLE TAMPICO FAX (760) 777-701 1 4,Y Y Y LA QUINTA FINANCE DEPT. :LA Q INTA, CALIFORNIA 92253 INSPECTION REQUESTS (760) 777-7153 BUILDING PERMIT ;Application Number . . . .f04-00.004666_ Date 5/28/04 Property Address .. . . . . . 54920 AVENIDA JUAREZ APN: 774-266-009-16 -000000- Application description . . . PLUMBING Property Zoning . . . . . . . COVE RESIDENTIAL Application valuation 4000 Owner Contractor ------------------------ TERRY MICHAEL' ------------------------ RYS CONSTRUCTION & DRAIN SRVC INDIO CA 92201 (760) 578-6400- 78-6400WCC: WCC:EXEMPT WC: EXEMPT 09/30/04 CSLB: 610554 05/31/05 CCC: B -C36 ---------- ------------------------------------------------------------------ Permit . . . . . . PLUMBING SEWER Additional desc Permit Fee 30.00 Plan Check Fee .00 Issue Date Valuation . . . . 4000. Qty Unit Charge Per Extension BASE FEE ----------------------------- 30.00 Special Notes and Comments -------------------------------------- SEPTIC ABANDONEMENT/SEWER CONNECT Fee summary Charged. Paid Credited Due Permit Fee Total 30.00 .00 .00 30.00 Plan Check Total .00 .00 .00 .00 Grand Total 30.00 .00 .00 30.00 w ! P.O. Box 1504 VOICE (760) 777-7012 78-495 CALLS TAMPICO FAX (760) 777-7011 LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153 BUILDING & SAFETY DEPARTMENT Application Number: 01 6 Date: Applicant: /' Architect or Engineer: — Applicant's Mailing Address: 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 orce and effect. License Class .C�l License o. O .� S Date ✓ / Q / Contract OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that 1 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 the applicant to a civil penalty of not more than five hundred dollars ($500).): U 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 purposeof sale.). U I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contrac: The Contractors' to Codede licensed pursuant to the Contractors' State License Law.). U I am exempt under Sec. , B.8 P.C. for this reason Date Owner WORKERS' 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 and policy number are: Cartier Policy Number y 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, ree that, if I come s bject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those pr ision . Date Applican WARNI : F URE 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. I herebyaffirm under y p 9 �, CONSTRUCTION LENDING AGENCY penalty of a 'u 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 Buildingand SafetyA 1. Each person upon whose behalf this application is made, each person at Permit ehose request st and ct to efoor whose benefit conditions and work ti rt cation. snperfortned under or pursuant to any permit issued as a result of this application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Quinta, 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 day* 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. 1 agre comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this county to ente-r. Vpon the abo nuo P for inspection purposes. Date 5 �� C/ Signature (Applicant or Agent): _Y � . Lr�, u 4. F, sit. i 'e°' , •5 `. e. ;.. ._S1 17 s . c- ss COACHELLA VALLEY WATER DISTRICT i r. CASH RECEIPT DETAIL 102184 Received From: %tet `.V (!'l C/ .•1ni Date• Address: Account No. % �� / (.• C:• �/ Lots// �" © ) C_:: Tract / >7Z, %f `- Service Address G.A. Code ; ^i 11 G_. ❑ Meter(s) $ ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s) ❑ Detector Check(s) Il ❑ Meter Surcharge - . sanitation Capacity Charge ❑ W.S.B.F.C. . ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name •. ❑ Inspection Fee -Tract - ` Fee - y? ❑ Plan Check Fees Water I Sewer - i Tract - fi> . I•. ❑ Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit c.. ❑ Other TOTAL Remarks: _- Cash `/t .`>f Water Service Check Money i Order )moi i Cashier J j +ta ER CVWD-438 (11189)