0107-003 (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, a,.� my License is in full force and effect.
License # +1r Lic. Class Exp. Date
43V4fYt+
Date 7- Signature of Contractor.!
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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:
Cartier Policy No.
iiixrx rum •PI
(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.
NDate: `Z •gz r` ar` a' Applicant—
Warning:
pplicant .. ,.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees. +r•
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 160 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
ffSignature (Owner/AgentDate
BUILDING PERMIT PERMIT#
DATE VALUATION LOT$�� TRACT
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JOB SITE APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/EN (NEER
17 9-800 HORSH'930HROM M03 'CIAM%CYST 1710. XW?. Q� Cr.'e.9Z20).
Lr.=tti 9afNITA. CA. 92253 PALM DMIRT cpp 92261
�7C�U;f346.2793 CKA, 342
USE OF PERMIT
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VAL11:A`X.ICA4 Z15-910
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PLUMBray M 811WI 11 101-000.419..000IMAP, TKI-_CO�4 -moil .0rD P1
PL UYT F '"V191:9 Do'.9NOW tt X) M
JUL 2 2001
FRMI ..✓ 1
i
CITY OF LA OUINTA
FINANCE DEPT
FECEIPT DATE BY S DATE FINALED INSPECTOR
-
1
�dy
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Form'9 & Footings
Ducts
Slab Grade
Return Air
Steal
Combustion Air.
Rodit-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 _ /� –
/�C���
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection evil—
Gas Piping ��
GasEncapsulation
_
Test
Appliances
Final
COMMENTS:
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)
,
_ ` QIHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
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Received From: U k .
I / y '
a
Address: —800
Account No.
• • Lot(s)
Service Address s
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
A Sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑. Inspection Fee -Tract -
Fee - '
❑ Plan Check Fees Water / Sewer -
Tract -
0. Bond Payment - A.D. -
Bond
Assmt.
❑ Customer Deposit
❑ Other
• . '• %•�
Remarks �1 � � 1 %u��'
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.1A)�' l�Q. Y/Of
1
7Copy to:
Money
Order
9 0841,40-41
1� 0
Date'
G.A. Code
Water Service
Cashier
a,h �h} , CVWD-438(11189)
.._ ... .. �. ...
;7 "... ..r.... . _....... .... , ..... _
EC SEWER SERVICE, INC.
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261
(760) 346-2793 (760) 328-7760
JOB WORK ORDER
14637
FAX (760) 347-4978
DATE OF ORDER
SERVICE CODE
PHONE
TE N IAN
HELPER
STARTING DATE
TOTAL LABOR
7 g
BILL TO
TYPE OF WORK
❑ CLEAN DRAINS
❑ OTHER
ADDRE
WORK ORDERED BY
TOTAL AMOUNT
_
SEPTIC_TANK
CITY❑E
TRAP
EEPAGE PIT
JOB NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 11/2% PER MONTH CHARGE AFTER 30 DAYS.
DESCR ON OF WORK:
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
/_
❑ No one home ❑ Total amount due 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
i d
WORK ORDERED BY
TOTAL AMOUNT
_
❑ No one home ❑ Total amount due 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