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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.
License # Lic. Class UP. Date
2/28/9'
Date �` 1,3 {�%�, 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 offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, 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 i
issued Myu workers' compensation insurance carrier, & polic no. are:
Carrier 5 A r� i V 1� a fv» • Policy No. Ioio') IP11): EZ i
(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 Jo become subject to the
workers' compensation laws of California, and agree that if I should become
subjecttot the workers' compensation provisions of Section 3700 of the Labor
Co e, I s�}all forthwith comply with those provisions.
l
;ate:...r , J! Applicant f v)..,,r/�_
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 Stage laws relating to the building
construction, and hereby authorize representai1ves of this City to enter upon
the�above-mentioned property
for Insppe'cti/on purposes.
Signature (Owner/Agent) /1a tit .l�g� r Date ��1
BUILDINGPERMIT PERMIT# CONTROL#
DATE VALUATION LOT. S%05-11IS TRACT 3 3 6 6
�raztnt; s�}.� ,
JOB SITE APN
ADDRESS 5.1-740 A'1rEiNWA BIAS 773-121-669
OWNER CONTRACTOR / DESIGNER / ENGINEER
fXX!At,D ,A 1ZY1 T)
S1*140AWN fbijt DLAZ
1,A. QUINTA CA
� .
USE OF PERMIT
A-} C'ESS.COO€, SERWICT, INC
16819 LITILF:MORONi. 0 RD.
92 25 3 DESERTHM'SPRING, CA 142240
i6l9'3:ix��-"75 Cl3}.ff W
S13W0.1 C ONNHC.V/SY:I'TI ADA14DON
't AL134 l i0N
1.2,550,0 LS
ii.91 IMSI'IE9 E ;CKVI` OF C:ONS'f°it()i"TION
}'VII4141}1' PLE, 811110MARV
�1lI3-T1\ tN�3}'If"I'tt7N a/lNf? I,�i3 L}IfCf4 3.3L+.ElU
1'i 'VAL li'1H:1< M 11' 1CF3 OUR NOW �..ill.tlt3
.
DATE BY DATE FINALED INSPECTOR
� 6112 210 1 lip] 0
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 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
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Ap is
71
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
TemF,. Use of Power
Final
Utility Notice (Perm)
❑ Customer Deposit
❑ Other
Remarks: t
❑Copy to:
Cash
Check ✓' ���
Money
Order
v r w L X -7 • it -D: r
Tract
G.A. Code
a
TOTAL
Water Service
Cashier
CVW D-438(11/8 9)
�no.mvou ruin/ i
F Address:
' - Account No. Lot(
r . Service Address
l
❑ Meter(s) /
.❑ Service(s)
❑ Backflow(s)
❑ House Laterals)
❑ Detector Check(s) r
❑ M Surcharge c
Sanitation Capacity Charge X5.5
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
1,
'❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond .
❑ Customer Deposit
❑ Other
Remarks: t
❑Copy to:
Cash
Check ✓' ���
Money
Order
v r w L X -7 • it -D: r
Tract
G.A. Code
a
TOTAL
Water Service
Cashier
CVW D-438(11/8 9)
A-1 CESSPOOL SERVICE, INC. JOB INVOICE
P.O. Box 183
Desert Hot Springs, CA 92240
� IMr, rasa
(619) 329.6875
CUSTOMERS'S ORDER NO.
DATE ORDERED
State LIc. #265214
ORDER TAKEN BY
DATEP
O0D
Pumping Fee per 1000 gal.
BILL TO `
PHONE
ADDRESS -1 �}
i GtIG��Z.
MECHANIC
CITY t "'
i C. -�,
HELPER
it
JOB NAME AND LOCATION
O Lltzx
AY WORK
Dumping Fee per 1000 gal.
- DESCRIPTION OF WyyORK �,
O CONTRACT
❑EXTRA ,
V ` i
QUANT.
DESCRIPTION OF WORKPRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Slze System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR WILL BE
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
QUANT.
LABOR AMOUNT
TOTAL
MATERIALS
MECHANICS @
TOTAL
LABOR
HELPERS ®
,,ff
I herebgackowledge the satisfactory
com letlon of the above descn'bed work:
TOTAL LABOR
TAX
SIGNATURE /
ATE COMPLET
"/0
LLOTAL
Under the California Mechanics Lien Law any contractor, subcontractor,
laborer, supplier, or other person who helps to improve your property, but
is not paid for his/her work or hearing, your property could be sold by a
court officer and the proceeds of the sale used to satisfy the indebtedness.
This can happen even if you have paid your contractor in full if the
subcontractors, laborers, or suppliers remain unpaid.
To preserve their right to file a claim or lien against your property, certain
claimants such as subcontractors or material suppliers are required to
provide you with a document entitled "Preliminary Notice". A Preliminary
Notice is not a lien against your property. Its purpose is to notify you of
persons who may have a right to file a lien against your property if they are
not paid. Generally, the maximum time allowed for filing a claim or lien
against your property is ninety (90) Days after the completion of your project.
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY,
YOU MAY WISH TO TAKE ONE OR MOREOF THE FOLLOWING STEPS:
1) Require that payments be made directly to subcontractors and material
suppliers through a joint control. Any joint control agreement should include
the addendum approved by the Registrar of Contractors.
2) Issue joint checks for payment, made out to both your contractor and
subcontractors or material suppliers involved in the project. This will insure
that all persons due payment are actually made.
3) After UPON making payment on any completed phase of the project,
and before making any further payments, require your contractor to provide
you with unconditional lien releases signed by each material suppliers,
subcontractor and laborer involved in that portion of the work for which
payment was made. On projects involving improvements to a single family
residence or a duplex owned by individuals, the persons signing these
releases lose the right to file a claim against your property. In other types
of construction this protection may still be important, but may be as
complete. TO PROTECT YOURSELF UNDER THIS OPTION YOU MUST BE
CERTAIN THAT ALL MATERIAL SUPPLIERS, SUBCONTRACTORS OR
LABORERS HAVE SIGNED.