0108-112 (PLBG)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
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:
N( > I, as owner of the property, or my employees with wages as their sole
.dompensation, 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).
(kl am exemp/t•' under Section , B&P.C. for this reason
spate f l:, ;T/ Signature of Owner " i°` .... •X•� �P."^ f",
DECLARATI
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.
(This section need not be completed if the permit valuation is for $100.00 or less).
(t ) I certify that in the performance of the work for which this permit is issued,
I •Mall 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.
Warning: Faijure to secure Workers' Compensation coveragd''is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compe Isation, 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 for inspection purposes.
/Signature (Owner/Agent) 4' • • -" Date '' UVVI
BUILDING PERMIT PERMIT#
DATE x`� .: ^� �. VALUATION LOT 0109--U2 TRACT
JOB SITE `""^•
APN
ADDRESS
31,416 MUER 0,100.0
-
OWNER
CONTRACTOR / DESIGNER / ENGINEER
CA 922.13
C5.1 ai
USE OF PERMIT
�i'6a��3�Tf::a1:�3d�'i!tltc'�'•,N � �'LrWift4�.':l`.°C�8I3.t;C." ,
VALUAVOW 1,200.00 us
MIND
�t AUs j
® 2001
,I• .b• Co
TOTAL PlfJI M= KED DUE 11,90W
RECEIPT _
DATE
BY
DATE FINALED
INSPECTOR
/I
J
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
SIT Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
.F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final I I
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond s
Footings
Main Drain
Bond Beam
Approval to Cover/
Water Piping
Equipment Location
Plumbing Final
Underground Electric
Underground Plbg. Test
Final
I I
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
Sewer Connection^ �
Gas Piping
V11& g
,.l��
Pool Cover
Encapsulation
Gas Test
COMMENTS:
I Final
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COACHELLA VALLEY WATER DISTRICT
Received Frq
CASH RECEIPT DETAIL
N.
I ,-! ✓p
Date-,
Address:
Cash
Check
Money
L r.
Accot;nt No.
Tract
Service Address
G.A. Code
0 yeter(s)
$
0 Service(s)
0 Backflow(s)
0 House Lateral(s)
0 Detector Check(s)
0 Njoter Surcharge
i6 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 I Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
-0 Customer Deposit
0 Other
Remarks:
.14
TOTAL $ 7
Water Service
Cashier,,_!e/,
I,," "CVWD-438 (11189)
,C] Copy to:
Cash
Check
Money
Order
.14
TOTAL $ 7
Water Service
Cashier,,_!e/,
I,," "CVWD-438 (11189)
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 "Owner/ 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 performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the 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.
i
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 than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks 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 under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without 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 the property owner is providing his or her 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, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the 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 SIGNA E/DATE
PROPERTY ADDRESS Ile
h2 2 --
PERMIT NUMBER(s)
r
A-1 Cesspool Service, Inca::�... _
P.O. Box 580188, North Palm Springs, CA 92258 JOB INVOICE
`Since 1959'
(760) 329-6875 Fax (760) 251-3405
State LIC. #265214 Customer Order No. Date t9Q/rd�ered
-5101
www.alcesspool.COM Order Taken By Date Promised
/091(00)
BILL TO
Eumoo EWvl WAL -
ADDRESS5 141 U r� le— LO I Lo �cl�
CITY E ^ Oil
n( a , HELPER
JOB ADDRESS
SERVICE PUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP7 • Yes ❑ No MT. ON SITE
REQUESTED ❑ PUMP SEEPAGE PIT AT ITS RISER
❑ OFFICE BILLING
QUANT. nGcrororrnra no hUni INT
Pumping Fee per 1000 Gallons (or fraction)
Waste Discharge•Fee per 1000 Gallons
Locating and Opening Fee (lhr. Min.) 1
Out of Area Fed
I
14
V
1
A
e
4r 60 ✓ .
w '
_ U
❑ THE LEACHING SYSTEM HAS FAILED. I -
. ❑ THERE IS AN OBSTRUCTION "UPSTREAM" OF THE SEPTIC T414K.
It will be necessary to contact a line cleaning company.
❑ WE RECOMMEND MAINTENANCE PUMPING OF THE SEPTIC WANK EVERY
❑ YEAR ❑ OTHER YEAR ❑ 2-3 YEARS
To remove built up solids. This will imaease the life of your leaching ystem.
❑ THIS PUMPING WILL PROVIDE ONLY TEMPORARY RELIEF AdDNOT
SOLVE CUSTOMERS SEPTIC PROBLEM BECAUSE OF THE ABOVE.
❑ CUSTOMER HAS BEEN GIVEN AN "EXPLAINATION' PACKET_ -
•
-• _i
A SERVICE CHARGE OF $22 WILL BE DUE _ - ;=_ ,
•'
ON ALL RETRUNED CHECKS.�^t
a
A FTNANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAS, WILL BE ;•��.r. , }
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
IF PAYMENT IS BY CHECK
DRIVERS LIC.# STATE
I hereby acknowledge the satisfactory completion of the above described work:
SIGNATURE
Total
N
Due