0211-117 (PLBG)LICENSED CONTRACTOR DECLARATION
I hm,eby affirm under penalty of perjury that I am licensed under provisions of
J__qA 9 (commencing with Section 7000) of Division 3 of the Business and
fV Cn �. Professionals Code, and my License is in full force and effect.
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. O :5 M~ License # Lic. Class Exp. Date
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202114 .9 1142, WC V-5/03
Z � Date A-7 Signature of Contractor
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>� 0/ OWNER -BUILDER DECLARATION
LU, LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ 'a License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
0 N
CA
d Q WORKER'S COMPENSATION DECLARATION
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H Q (.) 1 have and will maintain a certificate of consent to self -insure for workers'
X W compensation, as provided for by Section 3700 of the Labor Code, for the
m_ Q performance of the work for which this permit is issued.
Q U (') I, have and will maintain workers' compensation insurance, as required by
Q U Q S(' i)' X3700 of the Labor Code, for the performance of the work for which this
cl� U0H permit is issued. My workers' compensation insurance carrier & policy no. are:
ao Z Carrier 3T'.A3'Pt? FUND Policy No. 046-OOOM,41.
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g (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' provisions
Date: 111- -IA 11Applicant !- •4+! i i,r. Vii.. -
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 hib',t.,
application.
1. Each person upon whose behalf this application is made & each person it'
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) 11 i' ryey M_ Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
II/1smJOB SITE
�1t,S�Cd 9
ADDRESS �N/i« 1+ A�+i,}'�Fli"1A:Ci3� APN
OWNER ICONTRACTOR / DESIGNER /ENGINEER
RIC .: Domm. v,
A.4.0466AV.lsi� DAVE,. NSCO
�► C>UA .
USE OF PERMIT
PLI)IMM
A S' CRAMPCiCJ1, MRVI -E, INC
.P, 0,ruoxIia ...
CA 922,53 D1?,1;1n!RT1-.1*Ur3PR19CY1 CA 92240
060)329-6875 CTILO 0386
SKP`P1C ABA,tdVOWMEN°i;; SQ A. CUNNWT
MUMYAD CCAS OF C""OMMUMON ti Mo
PLU161141NO FEE - MYER 101-000-419-000 $30,00
SUB.,'Rn P:L,J. V 01RIM $30,00
e
NOV 15
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT DATE BY DATE FINALED 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
i F.A.U.
Framin,q
Compressor
Insulation
Vents
Fireplace P.L.
1 Grills
Fireplace T.O.
j Fans & Controls
Party Wall Insulation
; Condensate Lines
Party Wall Firewall
Exterior Lath
!
Drywall - Int. Lath
i
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. 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 / /
Sewer Connection J�
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final _
Utility Notice (Gas)
ELECTRICAL 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:
A-1 Cesspool .Service, Inc.
P.O. Box 580188, North Palm Springs, CA! 92258
`Since 1959'
(760) 329-6875 Fax (760) 251-3405
State Lic: 9.265214.., ,
www.alcesspool.com '
JOB' INVOICE
BILL TO M PHONE,
r.
ADDRESS n N E • ` , CLC.� TECHNICIAN_. ?' y
CITY (J 711, v HELPERR '
L
JOB ADDRESS }
' t _
SERVICE 0FUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP? ❑+',Yes ❑ No ❑ PMT. ON SITE
REQUESTED Q -PUMP SEEPAGE PIT AT ITS RISER .19 -OFFICE BILLING -
1--�) MUD 10S 17 f::OF, ILN-B A W0 WM E0 .
QUANT. DESCRIPTION OF PRICE AMOUNT
VxlmQ
Pumping Fee per 1000 Gallons (or fraction)
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee (I hr. Min.) • --
Out of Area Fee ,
❑ THE LEACHING SYSTEM HAS FAILED.
❑ THERE ISAN OBSTRUCTION "UPSTREAM" OF THE 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 yo,s leaching system.
❑ THIS PUMPING WILL PROVIDE ONLY TEMPORARY RELIEF AND NOT
SOLVE CUSTOMERS SEPTIC PROBLEM BECAUSE GF THE ABOVE.
❑ CUSTOMER HAS BEEN GIVEN AN " EXPLAINATIOI•d" PACKET.
'
. A SERVICE CHARGE OF $22 WILL of DUE -
ON ALL RETRUNED CHECKS.
A FINANCE CHARGE OF 1 1/21A PER MONTH,18% PER YEAR, WILL BE
CHARGED ON PAST DUE ACCOUNTS OI ER 30 DAYS.
IF PAYMENT IS BY CHECK .
DRIVERS LIC.# - STATE
1 hereby acknowledge the satisfactory c-00"on of the above described work:
SIGNATURE n , � (�, ,Aim
�Ml ��
IGA
Due
1
'7P Remarks:
yto:
Cash
Check I Z�
Money a
Order
c
Z & R ENTERPRISES, LLC
1912 PLANT AVE. #A
REDONDO BEACH, CA 90278
Y
IOUNT
N° 92485.
Water Service
--�
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Cashier
CVWD=438 (11189)
EXPLANATION AMOUNT J
128
16-66-1220
DOLLARS CHECK
DATE TO THE ORDER OF
Y COACHELLA VALLEY WATER DISTRICT
CHECK
NUMBER
CASH RECEIPT DETAIL
Received From: ZT
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Address: 12—
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Account No. �CAo V J , �� . Ci ,
�G ol(s) s /� 1;<
Service Address 4 iD U
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
1
❑ House Lateral(s)
❑ Detector Check(s)
❑ Meter Surcharge
VIranitation Capacity Charge 5 S
❑ W.S.B.F.C."
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account- Name
❑ Inspection Fee -Tract -
Fee -
❑ Plan Check Fees Water 1 Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
1
'7P Remarks:
yto:
Cash
Check I Z�
Money a
Order
c
Z & R ENTERPRISES, LLC
1912 PLANT AVE. #A
REDONDO BEACH, CA 90278
Y
IOUNT
N° 92485.
Water Service
--�
i
Cashier
CVWD=438 (11189)
EXPLANATION AMOUNT J
128
16-66-1220
DOLLARS CHECK
DATE TO THE ORDER OF
- DESCRIPTION
CHECK
NUMBER
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BankofAmerica®
* MaManan Village '��
7010 Sep tk hCA C�/�//i/FAL✓
Ma.884.1 Beach CA
310.084.1070 '
11@00 11 2811' 1: 12 200066 Ill: 108 18-0 1048u'
AMOUNT
$ /9zs . �•
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