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0108-132 (PLBG)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 Pro!essional�Code, and my License is in full force and effect. License # ' Lic. Class Exp. Date Date'''," Signature of Contractor { • w, •...—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 Sianature 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 Me 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•4hos'e`prouisions Date: C"' "'- t'!` Applicant' _ Waning: Failure to secure Workefs"&IRpeasatiaa.Goverage 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 the above-mentioned property for.inspection purposes. Signature (Owner/Agent) . /%`• Date C f ~ ------------- BUILDING PERMIT PERMITN DATE .VALUATION LOT 0100.132 TRACT JOB SITE APN ADDRESS 19-775 WWWARD 110 DRIVE OWNER CONTRACTOR/DESIGNER/EN (NEER 79.775 W.0.7rWARD7110DIUVt 54035 CAAi3AZON RD. 72 DIO, CA. 9220) Q60)346-2793 C.TA 342 USE OF PERMIT 3C.'.PT1 .AARA'iaL'ONWKNT; SM ZR HWPX,--UP '9e.fit,P.0 ATJON 2250,00 I's UWAAM COST OF CONSURM7110K 21M.00 �'I;klA�iD31}D� �•'�� .. �i;'9iT6?� 1431-�3t3�t 1 � 4Ci�► �3d.i�3 r.�'WLYCMONJS1:03 Pz,&W CMg,M $30.001 LEM PRE -PAM FFM SUO ffrrffrYOFLAQUIMTAA 2002xA nw'rm D1U.K NOW ,�.) RECEIPT DATE / / BX DATE FINALED INSPECTOR is INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set 4acks 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 I 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 Sewer Connection—Ilai S Pool Cover Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) t 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: COACHELLA VALLEY WATER DISTRICT 7�0 JV -2, - /171c CASH RECEIPT DETAIL wo ♦ 0+4�� _O t1N c" L.EJ0 y Y Cc" ,Q ' �C l _ vx :.. _ Received From: v `, Date r" e � d Address: L7 - "77S- A0 441 - — — - - - J n // //�� Account No: V %(O .(1 • Lot(s) Service Address79-9- 7 Z W S7 VVAX4_\ 140� ❑ Meter(s) ❑ Service(s) ❑ Backflow(s) ❑ House Lateral(s), ❑ Detector Check(s) ❑ Meter Surcharge Sanitation Capacity Charge ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee -Tract - Fee - ❑ Plan Check Fees Water I Sewer - Tract - ❑ Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit n n»,a. J� Remarks: i ° `� �f ✓' ' K Cashier //;;w ;✓ ]Copy to: /-4/ Cash Check o^r'�IDJ Money Order Flood plain plan Grading plan Subcontactor List Grant Deed H.O.A. Approval IN HOUSE: - Planning Approval Pub. Wks. Appr School Fees Plans picked up Plans resubmitted 2" Review, ready for corrections/issue Called Contact Person Plans picked up Plans resubmitted Review, ready for corrections/issue Called Contact Person Date of permit issue Tract G.A. Code J TOTAL $ �/ 2 J • OJ - Construction Mechanical Electrical Plumbing S.M.I. Grading Developer Impact Fee A.I.P. P. Total Permit Fees Water Service ' K Cashier //;;w CVWD-438(11/89) Construction Mechanical Electrical Plumbing S.M.I. Grading Developer Impact Fee A.I.P. P. Total Permit Fees EC SEWER SERVICE, INC. dba. ECONO SEWER SERVICES P.O. BOX 1'92 • PALM DESERT, CA 92261 (760) 346-2793 (760) 328-7760 JOB MORE ORDER 150Q1 PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1'/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 DISPOSAL FEE _v k SERVICE CODE TOTAL LABOR PHONE TEC IAN HELPER STARTING DRjTE BILL TO DATE COMPLETED TYPE OF WORK � 5—; V 4;6 ❑ CLEAN DRAINS ❑ OTHER A S f � ❑ SEPTIC TANK ❑ GREASE TRAP Cl (Mv ❑ SEEPAGE PIT JOB NAME AND LOCATION ADDITIONAL WORK NEEDED: TANK SIZE: PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1'/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 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. TOTAL MATERIALS DATE COMPLETED WORK ORDERED BY TOTAL AMOUNT Is 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