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, LICENSED CONTRACTOR DECLARATION
Ikiereby 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 Exp. Date
f 265214 C 411 2/28i99
Date 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).
( ) 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 -oft 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',5ection 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.
6169. M."V468
(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.
,9 ate: •� +�- 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 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
theeaabove-mentioned property for inspection purposes.
✓Signature (Owner/Agent) �y. '" Date BUILDING
�!-
PERMIT
DATE 1
2
1
$1/98 VALUATION 51.600.00 LOT
PERMIT #
yR312-11Kti
TRACT
JOB SITE APN
ADDRESS 773-1 11-01'7
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OWNER CONTRACTOR / DESIGNER / ENGINEER
VIOLA A-1. CT_`bSra00L SFRVECE,INKC
52.123 AVL141DA DIAZ 16819 LIT I LE h1:0R(7NGID ID.
T.,A. OUI A CA 92253 Dr.SL.it"T' H(3T SPRINGS CA 92240
(760129-6875 C13-1.4 396
USE OF PERMIT
PLUMBING
SEPTIC ABANDON, SEWLIIR CONNECT
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%��.�,�+�.ra a•cf,,i,v
i.,60V,03 I's
pp ;j,yyyTTF Fv g q /� qE .�6*ayf{:p-ti ALA
alS B7 .
K1JiV RING FEE - SEWER 101-M-419- MJ $:34, VU
.All
Stl17 "1"OTIN1., ICON Nt'Rr.t€:'7'!(-)19 ANCI P1,AN CiiECK
LESS PRIE-ACUD FEES
DATE I BY I DATE FINALED I INSPECTOR
1161110.010
$,-Y).00
$0, IN
530.00
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 8 Controls
Party Wali insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
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
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Ap liances
Final
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)
COMMENTS: !
i
FROW - JAK MFG
,FP.X NO. ' 760 568 *1090
COACHELLA VALLEY WATER DISTRICT
[.ARM RECEIPT DETAIL
Dec. '09 -1998 -07'27AM -P1
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Received f-rom:
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account No.
G.A- COCIO
service A.ddfO,U
L-1 Meter(s)
0 service(r.)-
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-1 Mouse Uffefal(-)
00
f 3 W.".8 -f -'C,
ri uncollected Account -NOMO�-
(-I In3pectlon Fee -'TraCA -
Fee --
C, plan ChqCj( Fe" Water I Sewer -
Tract-
L3 Sond Payment - A.D. .80f%d--
c4islamer Dow"it
Q Other
Ilk
Remarks:
TOTAL
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Check
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CESSPOOL SERVICE, INC. JOB INVOICE
P.O. Box 183 • Desert Hot Springs, CA 92240 v
-bince iv*v-
(760) 329-6875 • Fax (760) 251-3405
DESCRIPTION OF WORK
CUSTOMER'S ORDER NO.
DATE ORDERED
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State Lic. #265214
www.alcesspool.com
Gallons
ORDER TAKEN BY
DATE PROMISED
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ADDRESS
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MECHANIC
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CITY
HELPER
DESCRIPTION Q6WORK'
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✓ A
0 DAY WORK
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Out of Area Fee
0 EXT A
QUANT.
DESCRIPTION OF WORK
PRICE
AMOUNT
10elo
Gallons
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 1 1/2% PER MONTH, 18% PER YEAR
WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
QUANT.
LABOR AMOUNT
MECHANICS @
TOTAL
MATERIALS
HELPERS @
TOTAL
LABOR
I
I hereby acknowledge the satisfactory
h_
completion of tabovelde! d work:
TOT R
TAX
SIGNATURE
ATE -- LF.jED
Z Y
TOTAL
NOTICE TO OWNER 1q9
If 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 subcontractor, 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 MORE OF THE
FOLLOWING STEPS:
1) Require that payments be roade directly to subcontractors and
material suppliers through a joi i:t control. Any joint control agreement
should include the addendum api1roved by the Registrar of Contractors.
2) Issue joint checks for paymeknt, made out to both your contractor
and subcontractors or material ^uppliers involved in the project. This
will insure that all persons due ,ayment are actually made.
3) After UPON making payment on any completed phase of the project,
and before making any further f.ayments, require your contractor to
provide you with unconditionallien releases signed by each material
suppliers, subcontractor and la�orer involved in that portion of -the
work for which payment w6s made. On projects involving
improvements to a single family residence or a duplex owned by
individuals, the persons signing;ihese 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, SUBCOiNTRACTORS OR LABORERS HAVE
SIGNED.