0209-221 (PLBG)H
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that 1 am.licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the BuQrless and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
T552 14 C42 142C o7d2avlz,
(sate ' % i ��'`; "Signature of Contractor �
_. f
OWNER -BUILDER DECLAFI` TION
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.
6X,- 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:
Career STAII IeVNG Policy No. W6-00VW, 41
(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 hal forthwith comply with -0 ovisions.
bate: Applicant' ' Y?
X.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth. on his
application.
1. Each person upon whose behalf this application is made.&.each person at
Whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnity
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) _"%��r'��•.j, Date r` ,_ -
BUILDING. PERMITPERMIT #..,�Y
DATE fZ VALUATi^r. cry�LOT TRACT
JOB SITE 1
ADDRESS 77-^{60 CAL"13MANGD APN 7�.I^.$�i . �L
? _4f;0 l C_°,p;;::L1i DURANGO
u ognwrA CA 92253.
USE OF PERMIT
Del' 1:1MiS.i 140
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t:
YA1..U.�, i ICyt3
CONTRACTOR / DESIGNER /.
A- t CFSffF CJf?l'.. � D]EwRV N C
D 0X 1133
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SUB-TYYfIAl. C'' ...81Ri: C ON AJ*ZD P'.L./N Cp. .0*:"
PERMIT 11XV 11r D rteNOW
SEP 2'� 2002
fflF EA p
S
RECEIPT DATE ,y r `*'••j �r BY <' ' ' DTE FINALED INSPECT
INSPECTM 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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
First
• BLOCKWALL APPROVALS
POOLS a SFAS
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
Sjwer Lateral
Pool Cover
Sewer Connection
�- �. d2
Encapsulation
Gas Piping
'as Test
Appliances
TA A, -C +
Final
Final p2
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:
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t
COACHELLA VALLEY WATER DISTRICT
CASH RECEIFr DETAIL
? 01-1785
�ln.
f !74 1 •' \.J ..�.
From.
:\,
pate•Received I �
Address: `r
itt
Account No.(
Lot(e) ` �;�;
Tract
tt ServiceAddrese
I
. c t_
G.A. Code
O Meter(s)
3
❑ Service(s)
❑ Backflow(s)
❑ House Lateral (a)
❑ Detector Check(s)
❑ Meter Surcharge
"nitation Capacity Charge
❑ W.S.B.F.C.
i
❑ Temporary Construction Meter
❑ Turn on Charge
j ❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
.4 Plan Check Fees Water 1 Sewer -
Tract -
❑� Bond Payment - A.D. - Bond
Assmt_
❑ Customer Deposit
❑ Other
..
TOTAL
i` ..xs•-'�.���
Remarks: -
i\..�'""i•• '\_�L'.0 Vim%
OCopy to:
Cash
CheckE J i
Money
rder
Water Service
l%
Cashler
CVWD-438 (111139)
A-1 `Cesspool. Service, Inc.,-
-j- -;—P.Q i ox 580188, North Palm'SjprrlW CA 92238'
`Since 1959'
(760) 329-6875 Fax (760) 251-3405
State Uc. #265214
www.alcesspooLcom
JOB INVOICE
SERVICE ❑ PUMP: SEPTIC TANK, HAS swriC TANK BEEN DUG UP7 ❑ Yer ❑'No � [3 PMT. ON SITE
ReQYESTED E3 PUMP SEEPAGE: -PIT AT ITS RISER ❑ OFFICE BILLING
Ptimping Fee;per 1000 Gallons (or fraction)
(ePfJ
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee (1hr. Mim) .
Out.of Area Fee
�TF
❑ THE LEACHING SYSTEM HAS FAILED.
❑ THERE IS AN oBST'RUC mI uPmEAM" OF Tm SEPTIC TANK.
Bwill benwmtmytD =ads iwdaw&gODRIP Y.
❑ WE RECOMMEND MAINTENANCE PUMPINOOF THE SOMC TANK EVERY
❑ YEAR ❑ OTHER YEAR ❑ 13 YEARS .
TocmowbuiltuptoM. Thiswillmaaeethehr."fYoeke Symm
❑ THIS PUMPING WILL PROVIDE ONLY TEMPORARY RELIEF AND NOT
SOLVE CUSTOMERS SEPTIC PROBLEM BECAUSE OF THE ABOVE.
❑ CUSTOMER HAS. BEEN GIVEN AN "EXPLAWATION^ PACKET.
ASERVICX CHAWE Of S22 RILL BE DUE
am ALL RPmumm C=_ CKB.
A'PINANCE CHARGE OF 1.113% PER MONM 18% PER YEAR, WILLB6
CHARGED ON PAS'IMUE ACCOUNTS OVER 30 DAYS.
,
IF PAYMENT IS BY CHECK
DRIVERS LIC: S STATE
I .ctDowl dl *AWY edmpMNn of me aboro amibDd wait
SIGNATURE
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