The URL can be used to link to this page

0204-241 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of HChapter 9 (commencing with Section 7000) of Division 3 of the Business and N W Professionals Code, and my -License is in full force and effect. G 5 M License # Lic. Class Exp. Date w4nS�i " 642UK ;% ' t32i�tfic� oZ r- �Date)� , Signature of Contractors �' et A>4 t O U (0 OWNER -BUILDER DECLARATION Ha I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: Z( ) 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). cr) () I am exempt under Section , B&P.C. for this reason ul O N Date Signature of Owner rn Q WORKER'S COMPENSATION DECLARATION p 2 1 hereby affirm under penalty of perjury one of the following declarations: Lo FZ Ir O () 1 have and will maintain a certificate of consent to self -insure for workers' X W L compensation, as provided for by Section 3700 of the Labor Code, for the Oro � Q performance of the work for which this permit is issued. Q (J (� ) I have and will maintain workers' compensation insurance, as required by Q U Q Section 3700 of the Labor Code, for the performance of the work for which this Il rn H permit is issued. My workers' compensation insurance carrier & policy no. are: It Z Carrier " NCH F ND Policy.No. 4 622 -G"�' ob C'1 g (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 3 subject to the workers' compensation pro"visipns of Section 3700 of the Labor Code, I sJ all for with comply with those provlslons. r � 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 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 authorise representatives of this City to enter upon the above-mentioned property' for iri p r tion purposes.r - Signature (Owner/Agenfi/ X14 D"ate BUILDING PERMIT t +PERMIT# v'� � 9 DATE VALUATION LOT $24W.00 LOT JOB SITE . APN ADDRESS'S.A VENYDA IAZ OWNER CONTRACTOR/DESIGNER/EN (NEER 3:3.666 AVENWA. DIAZ 840:43 C;tW AZ : N IND. W 10. CA 9220! LA.,Q10i'PA CA. M53 PA.T14 DRlSEiEi'F CA. 92261 (760)346-27,93 6 BBI 342 USE OF PERMIT F>iiPa3'�"�1� A�A3�i3:30A? � S�tr'��.Yg {�NAiLC's2iD14' if P�+g�.�c'y�p�+ p�y� oy^��p A.. s ry,��,� p)�-� y�r��p * —S R AI.AV:E.�Tl;:i1l�� 6A,3+;3y OF R.�ll'i�>7d�.�'.CL��•:d. J.`iF�+t /� (� 401* 10 P 3 PPR 3 CITyOFLAQUINTA FINANCEDEP?_ ; 3R:r ATw. SKdYfL(1,�YdJCJ1FY ANY)YCdq/P ' 1..r➢�4A iR1.£��.�tA1Sf REV'S yAIyy �r '1'�ir , s D��CA�' �� PF10.11T �7 ! :1XIE iGk RECEIPT DATE' % BY r DATE FINALED 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 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 �!• • O'1/ Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: �, Final _ Utility Notice (Gas) Q ELECTRICAL APPROVALS Temp. Power Pole y 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 Received From: '. Ij Address: Account No. ' Lot(k) . Service Address Cash 0 Meter(s) Check LJ+ 0 Service(s) 10 Order tJP Backtiow(s) 0 House Lateral(s) Detector Check(s) 0 Meter Surcharge Vj,,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 - Fee - 0 Plan Check Fees Water I Sewer - Tract - 0 Bond Payment - A.D. --Bond Assmt. 0 Customer Deposit 0 Other er:--,Z: / G.A. Code $ TOTAL $ Water Service Cashier CVWD-438 (11 /89) Remarks: 0 COPY to: Cash Check LJ+ Money 10 Order er:--,Z: / G.A. Code $ TOTAL $ Water Service Cashier CVWD-438 (11 /89) EC SEWER SERVICE, INC. dba ECONO SEWER SERVICES P.O. BOX 192 • PALM DESERT, CA 92261 (76011346-2793 17601 328-7760 JOB WORE ORDER x15291 PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 11/2% PER MONTH CHARGE AFTER 30 DAYS. DESCRIPTION OF WORK: 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 FAX (760) 347-4978 DATE Of ORDER SERVICE CODE PHONE T HNICIAN HELPER STARTING DATE BILL TO TYPE OF WORK ❑ CLEAN DRAINS ❑ OTHER ❑ SEPTIC TANK E) -GREASE TRAP ❑SEEPAGE PIT ADDRESS 67 673 CITY 1�el, DATE COMPLETED JOB NAME AND LOCATION TOTAL AMOUNT ADDITIONAL WORK NEEDED: TANK SIZE: PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 11/2% PER MONTH CHARGE AFTER 30 DAYS. DESCRIPTION OF WORK: 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 ❑ No one home ❑ Total amount due Signature for above work: or I hereby acknowledge the satisfactory completion of the above described work. ❑ Total billing to be mailed after completion of work TOTAL PUMP 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 Signature for above work: or I hereby acknowledge the satisfactory completion of the above described work. ❑ Total billing to be mailed after completion of work