0107-090 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Ch2pter 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
Date;',`�"621 Signature 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 off 3red 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 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,, shall forthwith comply with dhose,proyisions.
Date: ti,� l,')•-l.°.r Applicant _—
�f,
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 to 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); ' ''' -- Date / P
�,.
BUILDING PERMIT PERMIT#
DATE VALUATION LOT NTRACT
JOB SITE APN
ADDRESS
OWNERSg� .1 CONTRACTOR
+/ DE�SIIG{}N7ECRf/E�yN61NNEpE7R
Ak�A.Vb dMLL'»L`YJd•!.'Rr�J e} A7�0,.�1L`"i cJ �IdLY'7.C�b� �2S:Si Y,l w�.n
L& QMNI A ("A 92253 Val -M DMEIIJt.'I.' CA 92261
1 Ci6O)346-2793 'MA 342
USE OF PERMIT
; EWR 1'tlOOK-#J'��iL�PTIt' .f.R}Vr,;ND09.W?NT
V.N-w; ATION
,1s4.i�ts J U L 1 0 2001 1
i
CITY QFA QUINTA
FINAN E DEPI
3�
, D"Inlw CObfor MM�eG'12�T4�``T'�t�i�
VKHMT Bpi .SIVAU . RY
PLUMBING M, 101-000-41M00
RECEIPT
01 -M -TOTAL CORPTRUC17015T AbW PLW, CJ-Maf. $30.00
T:i37C'AL PUMVT MAMS DBMS NOW $30AX)
DATE FINALED I 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
F.A.U.
Framing
Compressor ,
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines -
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
_
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Bond Beam
_
Main Drain
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
K. for Finish Plaster
Sewer Lateral
Sewer Connection _
Gas Piping
Gas Test
Appliances
—0.
Pool Cover
Encapsulation
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICR L 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)
Received From: J�0141y
Address: /?S140
21 J 41, ArIl
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
1/lIQ
as -
iRL '-'A C -A
4A
®8 40
_
: / Date Q f,/
Account No.
Lot(s)
ServiceAddress ob
Tract
G.A. Code
0 Meter(s)
$
0 Service(s)
0 Backflow(s)
0 House Lateral(s)
0 Detector Chdck(s)
0 Meter Surcharge
Sanitation Capacity Charge
0 W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee-Tract-
ee-Tract-Fee
Fee-
0 Plan Check Fees Water Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Cus tomer Deposit
A.,
0 Other
�J-
26:5
Remarks:
TOTAL $
ACopy to:
Cash
Check 14"
Money
Order I
Water Service
Cashier
EC SEWER SERVICE, INC.
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261
(760)346-2793 (7601328-7760
JON MORE ORDER
14894
FAX (760) 347-4978
DATE OF ORDER
r
SERVICE CODE
PHONE
TE I AN
HELPER
STARTING DATE
d
BILL TO -
+_ v�
TYPE OFCOORK
❑ CLEAN DRAINS
OT
TANK
❑ G TRAP
SEEPAGE PIT
ADDRESS �
OSEPTIC
CITY
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.
Good
mor '..
ery Poor
Roots
L;UNUI I ION OF TANK BEFORE SERVICE
_ Trash & Garbage _ Excessive soap
Overflowing _ Sand
Blockage _ _.Repairs Needed
_ Odor
_ More frequent service needed
Signature
❑ No one home ❑ Total amount due
for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
In Total billing to
be mailed after
4 completion
of work
TOTAL PUMP
DISPOSAL FEE
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
DA COMP ETED
WORK ORDERED BY
TOTAL AMOUNT
Signature
❑ No one home ❑ Total amount due
for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
In Total billing to
be mailed after
4 completion
of work