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0108-129 (PLBG),LICENSED CONTRACTOR DECLARATION I he, 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 Professznals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 746159 0,42111C Date'°^ `' /W 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 of perjury one of the following declarations: j () 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 d performance of the work for which this permit is issued. j ( 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: ? ". b','`� Applicant Warning: Failure to secure Wo kers' Compensation coverage is unlawful and sli`alt'sabjecfan•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 r application. f. 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. rf Signature (Owner/Agent)., '' ° ... _o Date BUILDING PERMIT PERMIT# DATE-' VALUATION LOT 0103_J_29 TRACT JOB SITE APN ADDRESS y y �y}�rp�,;�•� y •�•��g��. OWNER ` 'ry CONTRACTOR / DESIGNER / ENGINEER 'I "P -'J,55 WHO FTO. W41W, 84035 CAAW4 1W.rOWCIA 92201 Lk QVWTA CA 92261 (760) x46.2193 CFLO, 342 USE OF PERMIT S.` DTIC AXANDONIA.LMT; S'i, ,!Eft HOOK-UP VAl, ;fA1,10H 2,00.00 U1 ENIMATED COST OF CON1,11RUMOR NIUMBINCHITY _ SEWER 101-000-419-000 130.00 t� surra.,°Iw rA't'.r*MI'MUC'�.`0141 f 31PLAN'CT>?A''".i{: 030.00 s AUG 13 2002 OTAt FET&UN FES UV NOW M.90 CITY OF LA QUINTA FINANCE DEPT. RECEIPT DATE 7 BY DATE FINALED INSPECTOR /. I INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR } s. 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 BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final 4vater Piping Plumbing Final Plumbing Top Out Equipment Enclosure Sh9wer Pans O.K. for Finish Plaster Severer Lateral_ _ Sewer Connection � Gas Piping ' T/ 's 1 Pool Cover Encapsulation Gas Test Appliances 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) t COMMENTS: ;,eived Address: Accountl' Service Ai ❑ Meter(s) ❑ Service(s) . I"I Cnw Lil i,,..fc1 COACHELLA VALLEY WATER DISTRICT n Aeu CC!`CIOT nCTAII ❑ House Laterals) ❑ Detector Check(s) ❑ Meter Surcharge U/Sanitation Capacity Charge n -e ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name t ❑ Inspection Fee - Tract - ,. l - Fee - ❑ Plan Check Fees Water / Sewer - F Tract - ❑ Bond Payment - A.D. - Bond E: o Assmt. • ❑ Customer Deposit M n•l,e Remarks: ter' ,•—j,� a 'Copy, to: Cash Check Money Order Y --------------- resubmitted vieH•, ready for corrections/issue I Contact Person picked up resubmitted ,iew, ready for corrections/issue I Contact Person ifpermit issue $ TOTAL $ Water Service 1 Cashier CVWD-438 (11189) Construction Mechanical Electrical Plumbing S.M.I. Grading Developer Impact Fee A.I.P. P. Total Permit Fees i y d Flood plain plan Plans Grading plan Z,a R Subcontactor List Calle Grant Deed Plans H.O.A. Approval Plans IN HOUSE:- 3H Re Planning Approval Calla Pub. Wks. Appr Date School Fees --------------- resubmitted vieH•, ready for corrections/issue I Contact Person picked up resubmitted ,iew, ready for corrections/issue I Contact Person ifpermit issue $ TOTAL $ Water Service 1 Cashier CVWD-438 (11189) Construction Mechanical Electrical Plumbing S.M.I. Grading Developer Impact Fee A.I.P. P. Total Permit Fees i y d EC SEWER SERVICE, INC. dba ECONO SEWER SERVICES P.O. BOX 192 • PALM DESERT, CA 92261 17601346-2793 (7601328-7760 JOB NONE ORDER 15002 FAX (760) 347-4978 TOTAL PUMP DATE OF ORDER DISPOSAL FEE TOTAL LABOR SERVICE CODE PHONE TECH IAN HELPER STARTING DATE BILL TO WORK ORDERED BY TYPE OF WORK $ ❑ CLEAN DRAINS ❑ OTHER AD KESS r ❑ SEPTIC TANK ® ❑ GREASE TRAP CITY ❑ SEEPAGE PIT JOB NAME AND LOCATION 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: _ Good _ Fair _ Poor Very Poor _ Roots CONDITION OF TANK BEFORE SERVICE _ Trash & Garbage _ Excessive soap Overflowing _ Sand _ Blockage _ Repairs Needed _ Odor More frequent service needed Signature ❑ No one home ❑ Total amount due 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. h TOTAL MATERIALS DATE COMPLETED WORK ORDERED BY TOTAL AMOUNT $ Signature ❑ No one home ❑ Total amount due for above work: or I hereby acknowledge the satisfactory completion of the above described work. ❑ Total billing to be mailed after completion of work