0108-249 (PLBG)C0
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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
746159
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 Isnot 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 haver 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`
( ) 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.
101TATE FUND 0772211-01
(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' compensayon, provisions of Section 3X0 of the Labor
Code, I shall forthwith comply with those-proyisions,*=--
Date? -'I 6 r Applicant—
Warning:
pplicant Warning: Failure to secure Workers' C6mpensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000,, in
addition to the costof 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.l 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 �roperty for inspection purposes. r
Signature (Owner/Agentj,,I!:�' -- Date ,_11 1
BUILDI'WG PERMIT
DATE VALUATION '' LOT
79-640 CdJi=Z 141NE
RtIGR L hli147KE
119_6.4,C) COMM, diLF
LA. {1iJ11JTA
USE OF PERMIT
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APN
TRACT
84 03 3 CABAW.14 RD. RTMO, CA 92203
1>AU14, D ` .NT CA 92261
(760)3462793 Mai X42
1ST'MATIMM 006 CJ@' COXVIR7M7011' 2�1 11.t311
P4:LTA9BING FF., ••• `tM01. IM -000-4119-000 $i 0,00
:AWD 111 AH C"'1ilPIK $30.00
1 EM. 1W.,PEi101gM'B 1 $0,00
Yk'1 M IT D)'RFS ;t IE kiOW
FINALED
INSPECTOR
V0.00
MSIPECTM RLECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BULMNG APPROVALS
MECI AMCAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0. 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
SLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bend Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I
Gas Piping
PLUMMMO 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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTMCAL 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
17601346-2793 17601 329-7760
CJDo MORE ORDER
14935
- - -" - - - - -
-I--- - - -
FAX (760) 347-4978
-
DATE OF ORDER
SERVICE CODE
PHONE
TE ICI N -
HELPER
STARTING DATE
TOTAL LABOR
a
BILL TO
DAT OMPLETED
TYPE OF WORK
O
f
❑ CLEAN DRAINS
❑ OT
-ADDRESS
SEPTIC TANK
[:1 SE TRAP
CITY
/
L-.
SEEPAGE
PIT
JOB NAME,AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1lh% PER MONTH CHARGE AFTER 30 DAYS.
WNW I IUM Ut IANK IfttURE SEKVIUF.
4ai,
_Trash & Garbage _ Excessive soap
r _.Overflowing _ Sand
r _ Blockage _ Repairs Needed
_ Very Poor _ Odor
_ Roots _ More frequent service needed
❑ No one. home ❑ Total amount due
Signature for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
Total billing to
be mailed atter
completion
.of work
I
TOTAL PUMP
DISPOSAL FEE
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE,MAILED.
TOTAL MATERIALS
DAT OMPLETED
r' ORDERED BY
TOTAL AMOUNT
f
❑ No one. home ❑ Total amount due
Signature for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
Total billing to
be mailed atter
completion
.of work
Rsae•red Front. tea._
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