8111-175 (PLBG)LICENSED CONTRACTOR DECLARATION
%,l 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
265214 A2 :STC
Date�� - r 21 , Signature of Contracto r ^'r—•••r,rti �s�Y F- _ _ - _ -
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.
( ) 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 •��AT ,�UND Policy No. D66 -f3 DIY441
(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;,
bafe: /d 73 .°� z✓.Applicant__" p�.� , .4"r.•^ n' rnr—" p'��N9_
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
afety;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 f have'read this application and state that the above information is
correct..) 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-mentionedproperty f r inspection purposes
Signature (Owner/Agent)' fP���u' "� �'� rl - Date A
BUILDING PERMIT,
PERMIT #
DATE ��VALUJ,j�)N LOT
*�.�-•�
,y. *� TRACT
JOB SITE
ADDRESS :51_W AW.JV'a% VdA Ja�I
APN
OWNER_ _ _
CONTRACTOR/ DESIGNER/ EN61NEEER
-+TC-
411Iy—y M G sP+ELL
- qME SST, 001, S1lCJ--
1A QilINTA CA 92233
DESERT JFICIT 11PRPUM CA 52240
f
'N
tit;0].325-t'ws ono,
033,16
USE OF PERMIT
PLIJUBMG
SFP TEC .F>. SA14I: OW N101'r. ; SPOM, R CC21d1 IfriT
PLBJMk)WO Iii -w SEWER 101 t000.419i,000
Do
V
0 e EMkBi.710M AND PLAN %'rRZX
D
$30.00
L.S3 PRE -PAID EEP
$0,00
NOV 25 2002,.PEPIM rIr":Ox9URNOW
31M.09
CITY OF LA QUINTA
FINANCE DEPT
l'�
RECEIPT
DATE Y I` grgr� ! '
BYt.` `'
DATE FINAy�EID y�
INSPECTO
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
OX 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
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 I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Ytater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Slower Pans
Serer Lateral j
Sewer Connection l
O.K. for Finish Plaster
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
l fJergroind 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:
11/19/02 15:57 FAX. 760 568 3982 "' JARBELL•REALTORS 1@005/005.
'COACHELLA VALLEY WATER DISTRICT
CASH RECE_lpT.OUAIL may:
Racelved From:,1L
Address: ��—t�t� l i �l� I ` toCIO
Ica
�1 l ` r��yY Y ! 1
LOD
Account No. Ica 1 `� Lots) "'t + ac
Service Address Tr
_ n . �� G.A. Code
Tr `
❑ Meter(s)
❑ Servloe(s)
❑ BaWIDW(8), k
1
❑ House Lateral(a)
❑ DetectorCheck(L.
0,M Surcharg®. .
B/SAnitation.Capac 7herge P� 1
❑ Temporary Conett . ;Jon Meter
❑ Tum on Charge _
❑ Uncollected Accc -Name
❑ Inspection Fee -------------
1
❑ Plan Ctleck Fees ; ter! sewer
❑ Bond Payment - �, ,- ond_
0 Customer Depose
❑ Other
TOTAL $ r �t No
Remarks: s.
PCDPy to.
Ceeh ,
i YVat6r59rviceA
Check CI
"� •.
Ordery J rI ;,; _ Cashlar
ti CVwD-438 (71189) '
- ���_ • , .. ... .:il. Vii' , r . ,. .. lr :'!A'. \ . ,.
- it ^' ♦ - .
F
NOV-19-2002 TUE'04:45PM ID: PAGE:5
A-1 Cesspool Service, Inc.
P.O. Box 580188, North Palm Springs, CA 92258 -.JOB INVOICE
`Since 1959'
(760) 329-6875 Fax (760) 2514405
State LIC. #265214 Customer Order No. Date Ordered
1 VNWR'.a1CeSSp0.0_I:com Order Taken By DaterPro sed
BILL TO
0)v
ADDRESS TECH ICIAN
CITY HELPER
JOB ADDRESS - r i� r 'VA
C �6
i X' & t/ 1
c,t l/U 1"
SERVICE d PUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP? d Yes ❑ No❑ p . ON SITE
REQUESTED ❑ PUMP SEEPAGE PIT AT ITS RISER OFFICE """
nreroioTIMI
Pumping Fee per. 1000 Gallons (or fraction) .
OVV
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee (I hr. Min.)
Out of Area Fee ..
r -A-1 LATIC .
� l� ���nI�U�<I � C�� �• lrL__
4...
❑ THE LEACHNG SYSTEM HAS FAILED.
❑ THERE IS AN OBSTRUCTION "UPSTREAM" OF THE SEPTIC TANK
It will be necessary to contact a line cleaning company.
.
WE RECOMfA ND MAINTENANCE PUMPING OF THE SEPTic TANK E VERY-
❑ YEAR ❑ OTHER YEAR ❑ 2-3 YEARS
s
To remove built up solids. This will increase the life of your leaching system.
-
❑ THIS PUMPING WILL PROVIDE ONLY TEMPORARY RELIEF AND NOT
SOLVE CUSTOMERS SEPTIC PROBLEM BECAUSE OF THE ABOVE.
.
❑ CUSTOMER HAS BEEN GIVEN AN "EXPLANATION" PACKET.
-
A SERVICE CHARGE OF S22 WILL BE DUE
ON ALL RETRUNED CHECKS. '
A FINANCE CHARGE OF 1 112 % PER MONTH, 18% PER YEAR, WILL BE
_
• CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
IF PAYMENT IS BY CHECK
-
DRIVERSLIC. # STATE
//JJ
Total
1 hereby acknowledge the satisf la completl�ou of the above described work: .
slcrlA
Due