0107-221 (PLBG)LICENSED CONTRACTOR DECLARATION
1 hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) o Division 3 of the Business and
'Profaspiogials Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
j
Date %'�`i2" '' 6/signature of Contractor y
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 Policy No.
49TWIT's FUND
(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: !`2'1 '.°f:'J-•,�,1,QApplicant �r'•�,_.ff"
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 inspsp-ection purpoxses.
Signature (Owner/Agent),s ' --,- --vf �. Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0jl()7-^22,1 TRACT
JOB SITE
ADDRESS
OWNER
L A Cl•(WT..%
USE OF PERMIT
14"Li D413
ROAD
APN
CONTRACTOR/DESIGNER/ENGINEER
84.035 CAD.WG RD, 1Ni� ID, CA 92.201
CA. 92253 PALVEDESEN.r CA. -02261
/IISPi346- 193 03L4 3412
SEPTIC ,,€ SA?dDMIMEM; SE WMEX HOOK-UP
VAIX.P.MaN
XXTIM&M COST 01Y COTTSURITCTION
FLeRMU FU SUMMARY
%LUMM01PEE SWER 101.000.4-19-000 $30A
4--01 t 1r.1m �"� )1�� ANT O�3WIX S-40.00
I�r---
- ISS PRE-PAIDP I� $0.00
JUL 2 0 200
.g' JC 1�J6tiOi.,
Cil`!Of lA0U1(JIA
niii-.,xi DEPT
RECEIPTI DATE, -7 /3,, I Y C_ DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
- BUILDING APPROVALS
MECHANICAL APPROVALS
Y
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
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
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer
Pool Cover
Connection _ _ _
Gas Piping
Encapsulation
. Gas 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)
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
inp-f Re.
Received From:." Date:
Address: Est i -o, iz-, i? b 6� d( lv'f A
AccountNo. Lot(s) Tract
Service Address G.A. Code
• Meter(s)
• Service(s)
• Backflow(s)
• House Lateral(s)
• Detector Check(s)
• Meter Surcharge
Sanitation Capacity Charge
0 W.S.B.F.C.
• Temporary Construction Meter
• Turn on Charge
• U n collected. Account - Name
• Inspection Fee - Tract -
Fee -
• Plan Check Fees Water 1 Sewer -
Tract -
0 Bond Payment - A.D. - Bond
Assmt.
0 Customer Deposit
0 Other
TOTAL
A Remarks:
Copy to:
CashWater Service
Check
Money Cashier A,
Order
r';'. CVWD-438 (11/89)
EC SEWER SERVICE, INC.
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261
17r%ni -1aa_27a-'4 17ian►'49R_77an
JOB WORK ORDER
14902
' FAX (760) 347'4978
DATE OF ORDER
SERVICI= E
PHONE
TE NIC N
HELPER
STARTING DATE
BILL TO
TYPE OF WORK
❑ CLEAN DRAINS
E]OTHER
R-5E'PTIC TANK
❑ GREASE TRAP
®-s T P}1=rr
ADDRE S�'` �
7 (� / G^ -e-- C, w�
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.
DESCRIPTION
7 -4,c -
CONDITION OF TANK BEFORE SERVICE
_ Good _ Trash & Garbage _ Excessive soap
Fair _ Overflowing _ Sand
Poor _ Blockage _ Repairs Needed
Very Poor _ Odor r
Roots _ More frequent service needed
TOTAL PUMP I JU�r+I _ ---
DISPOSAL FEE
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TOTAL MATERIALS
DATE COMPLETED 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