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