0208-309 (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 i
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
746159 C42.1D }ep i
.Y
,eDate Signature of Contra
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 congant 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
Se tion 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 TFATE FUND Policy No. IM221-02
(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: C% L e Applicant - 0- - P --
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 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) ,• "� rDate .
• ",' BUILDING�PERMIT
PERMIT #
DATE 4t' VALUATION • LOT
TRACT
P�
JOB SITE
ADDRESS _4%3-12S, AVU%J. A VALLY
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
., RAH"I YOLAND,A.FATCURADA
r.CON0 81M ER 0 E RVIM;
53 -1 25VVEMDA, VAILWO
84035BAZOM .�, IX10,, CA92201
T.& Qvzrm CA922$3
xa.ATId3; �`►1�.�x.tERTC IZA 92M
(760)346r7793 (sBUt 342
USE OF PERMIT
PUDMIZ' O
F �,
r .a
SV f'C Rfi.ANDON; SWER HOOY.41P
,D
VALUATION
ZSD9,00 Is,
cl>1r
LAQUINTA
FIN
NCE DEPT:
r)JUMB)X1 101!1 E -- SEWFIR lo-1.000419.0o.o a ' $34, A0
S -TMAL Cf)NMUCV ION .AND PLAN AN CIJECK
$30.00
LESS M -:I AW F'REra
$0, 00
"O'11'AL rmwf1
M IS :I UI.I NOW
S��r1�tS�F
RECEIPT
DATE • :,'
�::�,.,:=?`'':�:1',�;N .ria
BY
i,•r..:!
D FLED
�-IN
INSPECTOr�
iG.%��
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 8 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
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
�j-� .�/
Encapsulation
Gas Piping
Gas Test
Appliances
_
1 l� _p< .a Til a2
`—
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)
Final
COMMENTS:
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL®
09-0943
i
"- ,..:
Received From:
Date.
�
Address:�' '. 1J: tP•c�2: C.! f! t % ,� £
}�clv../
Account No.�_%L`i
Tract
Service Address M'' -y - "il* c '? f/.�Ci r',' i� ��1/' / t .�
G.A. Code
❑ Meter(s)
$ i
❑ Service(s)
O Backflow(s)
❑ House Lateral(s)
1
• ❑ DetectorCheck(s)
❑ Meter Surcharge
!
sanitation Capacity Charge•-
❑ W.S. B. F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
i
❑ Inspection Fee - Tract -
i
Fee -
❑ Plan Check Fees Water I Sewer -
-
Tract -
I
❑ Bond Payment - A.D. - Bond
ti
Assmt.
!
O Customer Deposit
O Other
!
TOTAL
$
Remarks:
i
�
®'Copy to: '-' l •` i( -!G_.
Cash
WaterService l
Check j. e
Money
+_
Cashier
Orderrc`'
CVWD-438(11/89)
a
EC SEWER SERVICE, INC. 001 WORE ORDER
dba ECONO SEWER SERVICES ,
P.O. BOX 192 • PALM DESERT, CA 92261 15763
17601346-2793 17601 328-7760
FAX (760) 347-4978
DATE OF ORDER
_ Good
_ Trash & Garbage _ Excessive soap
�-:
G -z—
SERVICE CODE
PHONE
TECH ICIAN
HELPER
STARTING DATE
BILL TO
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TYPE OF WORK _
r
❑ CLEAN DRAINS
❑ OTHER
ADDR&SS
TOTAL AMOUNT
Is
JAe4
❑ SEPTIC TANK
❑ GREASE TRAP
clTv •
[:1 SEEPAGE PIT
JOIT NAME AND LOCATI
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE -11/2% PER MONTH CHARGE AFTER 30 DAYS.
ESCRIPTION OF WORK: ,
Pf,,107 142
Of
CONDITION OF TANK BEFORE SERVICE
_ Good
_ Trash & Garbage _ Excessive soap
_ Fair
_ Overflowing _ Sand
_ Poor
! _ Blockage _ Repairs Needed
Very Poor
_ Odor
_ Roots
_ More frequent service needed
Pf,,107 142
Of
�l ❑ No one home ❑ Total amount due L] Total billing to
Signature for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work
TOTAL PUMP
DISPOSAL FEE
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
DATE COMPLETED -WORK
ORDERED BY
TOTAL AMOUNT
Is
�l ❑ No one home ❑ Total amount due L] Total billing to
Signature for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work