9901-054 (PLBG)N
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
Signature nature 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 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.
( 1 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).
( ) 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, pfbvisions;
Kate: / 7 5; 21'7 Applicant 71
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 nulland 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 forinspection purposes.
�tr,�
Signature (Owner/Agent)' �Date;
PERMIT #
BUILDING PERMIT„_,;
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS ]1- 3 i 3 ( 'r+.1�li�➢.� V i!��.�Fn�{A APN 773.093-i)J9
OWNER CONTRACTOR/DESIGNER/ENGINEER
VALIX110 94035 CAWV,014 RD. INDIO, UL 92201
UA QC,fIX17A 1_:A 9223.3 PALM- DFS1Xr CA 92261.
CC81 A 142
USE OF PERMIT
8U_%ttC.ABAlv3. X. SL�'�Ii.�i%+CO ECT(L.P�E�i�C l #98-26) �
AeA!
y '
COMMA0 Ail! OVI% f 1,500.00 LS
EST IMATED COST OF CONSTRUCT WIN 1"m mo
PE.RAlfi FEE SUMMARY
PLUNI1 rNG FEE — SEWER 101 -NO -419-000
CF:f-T�!(�(:n�tTRUC"IT0N AND PLAN C1I:CK.?0 !m
LESS .PRE-lyr"t D FEES 0.tln
TOTAL 1<''E#tNUT F1;LS l;i)K:'NtiW MOO
RECEIPT DATE BY 1J (I DATE FINALED INSPECTOR
V-'
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
POOLS - SPAS
BLOCKWALL APPROVALS
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
Pool Cover
Sewer Connection — i
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final ,
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
ECONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
/7CA\ OAC 417410 /7CA\ 7410 77C9%
joo WoaK oq a
10798,x=
�i vv/ vw-c.i as %, vv/ vc. v -i i vv
FAX (760) 347-4978
--
DATE F ORDER
�/ -�'
CUSTOMER'S ORDER NO.
PHONE -
MECHA
HELPER
STARTING DATE
Nals---e. T WILL BE MAILED,
TAX
�G
DATE COMPLETED` •�
9 (7j
WOR E
BILL TO ` I
ORDER TAKEN BY
ADDRESS
amount due ❑ T al billing to
�f ^
❑ DAY WORK
/
❑ CONTRACT
CITY
❑ EXTRA
`/`
JOB NAME AND LOCATION
JOB PHONE '
DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE
11/:x.6 PER MONTH CHARGE AFTER 30 DAYS.
Signature f� �/ i� ',fo(above work: or be mailed after
completion
I hereby acknowledge the satisfactory completion '` of work
of the above described work.
TOTAL MATERIALS
TOTALLABOR
PLEASE PAY FROM THIS OC
Nals---e. T WILL BE MAILED,
TAX
DATE COMPLETED` •�
9 (7j
WOR E
.TOTAL AMOUNT
.� C,
❑ No one home /Total
amount due ❑ T al billing to
Signature f� �/ i� ',fo(above work: or be mailed after
completion
I hereby acknowledge the satisfactory completion '` of work
of the above described work.
• N:4
E.C.Sewer Service, Inc. dba
Econo Sewer Service.-,
YO Box 192 ,
Palm Desert, CA 92261
(760) 3.46-2793 or 328-7760
Fax (760) 347-4978 License C-42 #746159
Date:
RE: City of La Quinta
_Project 1198-20
Sewer Connection
the owner of properly at 13
(Print Name) (Print Address)
in the:City of La Quinta, release Econo Sewer Service of responsibility for restoring my property to
to it's of igina( state prior to the sewer connection. Please note the following areas they, are
;j
released fiom:,
2. l`
3.
4.
Signatrue,' f �66.-Kew&.Service Employee "roperty
I•�tll -
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