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0108-133 (PLBG)y LICENSED CONTRACTOR DECLARATION U I hereby affirm under penalty of perjury that I am licensed under provisions of I— Chapter 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. Z) ch License # Lic. Class Exp. Date t ~ � L., C42 (per 4102 r.. r f / Z r� Date ' f r Signature of Contractor rp 0�.- F/ v J U �" --'" --"OWNER:BUILDER:'DECLARATION UJ W r—I hereby affirm under penalty of perjury that I am exempt from the Contractor's ~ U) License Law for the following reason: a 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). ( ) 1, 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 • LO N Date Signature of Owner Q N 0) a< WORKER'S COMPENSATION DECLARATION. C:) 2 Cr I hereby affirm under penalty of perjury one of the following declarations: Lo <p () 1 have and will maintain a certificate of consent to self -insure for workers' X LIJ Y= compensation, as .provided for by Section 3700 of the Labor Code, for the m� Q performance of the work for which this permit is issued. Q () (, 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 a Z permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier Policy No. Q (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 1 Code, I shall forthwith comply with those provlslons ' rJ Date: yApplicant 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 370t3 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 ;lays will subject permit to cancellation. I certify that I have read this application and state that the above information S� • 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) ""-�a -^w^ Date *+ BUILDING PERMIT PERMIT# DATE VALUATION LOT ��."�,4` TRACT JOB SITE "" APN ADDRESS 79-1&15 WEINVAM HO Dpa'Afr. OWNER CONTRACTOR/DESIGNER/EN (NEER DIME I LA QUA. USE OF PERMIT S, 'fX,* ,AHA- 7®'fid if 9 f?alf 1 VAIUATIONi PALM URSERT CA 92261 060)346-27," CAIX 34-2 r P' fwnODICetD)c'�� 1IJ 4, 26150.00 12 PM- UT FRE SC3AsNU��ggyy�((gy�pp yY (�y rrts!!�yy��AA 44 CC11 p(+yyo�// II�� //yy pp�fpd RIX 0 re'I: -- RJJE 9 ER 101 �Fl �r17'"'t d .9-000 3'a t4 V V 11l XTO RIAM C;HF". I E" IRE -FAM R&M 2XV-00 $30.00 $0.00 ZOOZ t 9(Id TKYTAL P�-�R.MT FE)ES D NOW M.M r RECEIPT DATE % a BY. DATE FINALED INSPECTOR H INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION 11 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 BLOCKWALLL-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 Showpr Pans O.K. for Finish Plaster SeweCLateral Sewer Connection� (alp S Pool Cover Encapsulation Gas Piping r Gas Test Appliances Final COMMENTS: Final ��Z /4 / 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) Remarks. ❑Copy to:�� Cil-• i Cash .1 j Check 'V tD I Money Order , �7 COACHECLA VALLEY WATER DISTRICT - l`f _ f ( CASH RECEIPT DETAIL a r Received From: 1 G�Y�Ow� Address: -7�Q11y GX Subcontactor List Account No.` Lot(s) o- Service Address H.O.A. Approval . ❑ Meter(s) IN HOUSE: - ❑ Service(s) Planning Approval ❑ Backflow(s) Pub. Wks. Appr ❑ House Laterals) School Fees ❑ Detector Check(s) ❑ Meter Surcharge a; -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 1 Sewer - Tract - • Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit ❑ Other Remarks. ❑Copy to:�� Cil-• i Cash .1 j Check 'V tD I Money Order , Flood plain plan Grading plan Subcontactor List Grant Deed H.O.A. Approval IN HOUSE: - Planning Approval Pub. Wks. Appr School Fees 4NT0 08%565 (0-b-01 Date* Tract r C% G.A. Code 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 WaterService a L�•t ' J Cashier CVWD-438 (11189) Construction �r Mechanical Electrical Plumbing S.IN.1. Grading Developer Impact Fee A.I.P.P. Total Permit Fees EC SEWER SERVICE, INC. - dba ECONO SEWER SERVICES P.O. BOX 192 • PALM DESERT, CA 92261 `17601 346-2793 (7601329-7760 JOB MORE ORDER 15000 FAX (760) 347-4978 TOTAL PUMP DATE OF ORDER DISPOSAL FEE SERVICE CODE PHONE HELPER STARTING DATE TOTAL MATERIALS T- ,T�ECHNICIAN DATE COMPLETED WORK ORDERED BY BILL TO $ TYPE OF WORK yv ❑ CLEAN DRAINS ❑ OTHER ADDRESS - - ❑SEPTIC TANK ❑ GREASE TRAP CIT ❑ 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: 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 t�� 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 $ 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 t��