0107-087 (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, and my License is in full force and effect.
_Li• 3nse # Lic. Class Exp. Date
171 s C42 2OU102
Date�"�',�"�� Signature of Contractor��-------
r` �f
OWNER -BUILDER DECLARATION s
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: 1
( ) 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.
(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: 7.. =4� Applicant:
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
ofthe 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).r� a Date; /06 t
BUILDING PERMIT PERMIT#
DATE VALUATION i� LOT., ?� f •`�' TRACT
�
',lx�'ili3t
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER `
SAIM.'VNC' .
L�MrT3IM E`ERVICIR
'•7955() HC RUE -MOB 3:'D
84035 C<A33M01T RD, 3T*ID10, CA 9-4101
CA 92253
.TIA M;4?ESEXT CA 922:1
060)346.3793 CSU- :342
USE OF PERMIT
I� �
6 E rr„
VALUATION %;a�ap LJUL
10 2001
Ci TY
�LA
F!NAI
QUIN
OUINI A
CE DEPT'
_0_A_X_)I
??7,dgqyCon 010iONSIRUryd0.
2,00
FERAVE FEE 141MEN) Y
MUMBING H021 1 -000-419-000 $30.00
a
XY.83 MR -PAID 7M)
'00
TCVrAL?XMT MIN DUE NOW
$300AM
RECEIPT
DATE
BY
?
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
n,
BUILDING APPROVALS
OPERATION DATE INSPECTOR
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 Wall Insulation
Condensate Lines
Party Wali 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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
Sewer Lateral ^
Sewer Connection 1 ��/J
Gas Piping
O.K. for Finish Plaster
Pool Cover
Encapsulation
Gas Test
Appliances
Final
COMMENTS:
s
F' al
L104ty Notice (Gas) 2 7
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)
Remarks: o -V A' ...
11cop'y to:
Ciah
Check
Money
Orrior
G.A. Code
TOTAL $
N
Water Service
Cashier
rr
---
COACHELLA VALLEY WATER DISTRICT
iJ
CASH RECEIPT DETAIL
Received Fro m*LJ
Address
Remarks: o -V A' ...
11cop'y to:
Ciah
Check
Money
Orrior
G.A. Code
TOTAL $
N
Water Service
Cashier
---
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received Fro m*LJ
Address
AccountNo. -
Lot (s)
Service Address 9'S
0 Meter(s)
0 Service(s)
0 Backflow(s)
0 House Lateral(s)
0 Detector Check(s)
0 Meter Surcharge
19 Sanitation Capacity Charge
0 W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
Cl Uncollected Account - Name
0 Inspection Fee - Tract -
Fee -
0 Plan Check Fees Water I Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
'0 Other
Remarks: o -V A' ...
11cop'y to:
Ciah
Check
Money
Orrior
G.A. Code
TOTAL $
N
Water Service
Cashier
EC SEWER SERVICE, INC.
Oba ECONO SEWER SERVICES
P.O. 6OX 192 • PALM DESERT, CA 92261
(7601346-2793 (7601328-7760
M MORE ORDER
1490'0
• • FAX AX 760' 347-4978
DATE OF ORDER
Y
SERVICE CODE
PHONE
I TEC CIN
HELPER
STARTING DATE
��
I
BILL
TYPE OF WORK
❑ CLEAN DRAINS
❑ 0TH
EPTIC TANK
❑ GR i�TRAP
SEEPAGE PIT
ADDRESS
CITY
JOB NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1'/2% PER MONTH CHARGE AFTER 30 DAYS.
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
u
Signature
❑ No one home ❑ Total amount due
for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
[J Total billing to
be mailed after
completion
of work
TOTAL PUMP
J,
DISPOSAL FEE
1 17
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
!2COMPLETED
z /R� 0
WORK ORDERED BY
TOTAL AMOUNT
$/
u
Signature
❑ No one home ❑ Total amount due
for above work: or
I hereby acknowledge the satisfactory completion
of the above described work.
[J Total billing to
be mailed after
completion
of work