0108-219 (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
Prot*Ssionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date ' 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 isnot 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
1 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 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 h•those•p�evisibns.
Date4"!:� /'Applicant—
Warning:
pplicant ! g•
�. �
3'
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. 4•y
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)'� Datel��L-£mow=y
BUILDING PERMIT PERMIT#
DATE iJVAIJK''�,ITION LOT OIGS.=14 TRACT
JOB SITE
APN
ADDRESS
'
OWNER
CONTRACTOR/DESIGNER/ENGINEER�
l�.S..T�f IN'!#:� d� 1 YCr��. 1
:�.Y.A.•��.i[`CO ►QIP+ :45( aWV /A.i�
(W)346-7793 CRUt 34 2
USE OF PERMIT
sewor Cwi'i ect
I
VA4.6)ATICON ifs
A
x
SUR-"j:'MAL COAFMUC:'!'.:L0N 1i,? PLAK Cl =.
M.9•a(Q ,
LEMS l✓'l'"dEkPAR") FRED
$010101.
e
AUG 2 3 2001
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATE
BY:.' 4
DATEFINALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR
1
BUILDING APPROVALS
OPERATION DATE INSPECTOR
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
BLOCKWALL 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
Ger Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
SI•cwer Pans
Sewer Lateral
Sewer Connection — ` ✓ �'
O.K. for Finish Plaster
Pool Cover i
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
..:... Y` '-"t- '- •. Ns. T'i"-ice;+� fir' ' -+a r ,t . ., v ,. ��.�: .. aa,ic.. s - +^f�' :.n ^ r;=:
;. ..
45-500 Van Buren Indio, CA 92201 9 (619) 347-235E
SEWER CONNECTION, PERMIT
%To I Dan
Date Inspection Comments Inspector
FINAL ACCEPTANCE
.All items for which- this was issued have been inspected and meet Valley Sanitary District Standard
Specifications.
Signed: Date:
` WHITE - VSD CANARY - Annexation File ,PINK- Permitee - -
New Construction ... ❑
Addition .' .:... ...... ❑ Annexation No.
Repair/Alteration
Parcel No.
Owner: u n C!j
v\t Contractor:
Project Name:
License No.:
Project Address:
Phone No.
Comments:
Applicant Signature:
Issued by:"--r-).AAI Date: �
FEES
U.O.S. Rate Total
Due
Paid
Connection:.......
. ......... —x $ 27 cv . _ $
❑
Inspection:
Principal Lateral: `.......:......
x $ = $
❑
❑
Subsidiary Lateral
.......... x $ = $
❑
❑
Saddle: ..... . ................
x $ _ $
❑
❑ i
Disconnect: . ....
x $ _ $
❑
❑
Addition: ..............
x $ _ $
❑❑
Repair: ... .............
x $ _ $
❑�
Other:
x $ _ $
❑
❑
TOTAL FEES:...
$ :=t 0 %. G? Receipt No.
INSPECTION RECORD
24 Hour Notice Required Prior to Inspection
Date Inspection Comments Inspector
FINAL ACCEPTANCE
.All items for which- this was issued have been inspected and meet Valley Sanitary District Standard
Specifications.
Signed: Date:
` WHITE - VSD CANARY - Annexation File ,PINK- Permitee - -
EC SEWER SERVICE, INC. JOB MORE ORDER
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261 14 9 7 7
(7601,346-2793 (7601328-7760
FAX (760) 347-4978
DATE OF ORDER 11
17 ✓ �3— eJ /
SERVICE CODE
PHONE
TECH AN
HELPER
STARTING DATE
BILL TO
TYPE OF WORK
TOTAL LABOR
❑ CLEAN DRAINS
❑ OTHER
ADDRESS i
' `
LQ
❑ SEPTIC TANK
CITY _
❑ GREASE TRAP
tN
❑ SEEPAGE PIT
JOB NAME AND LOCATION -
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SE VICE 11/2% PER MONTH CHARGE AFTER 30 DAYS.
DESCRIPTION OF WOR
CONIXION OF TANK BEFORE SERVICE
Good _ Trash & Garbage _ Excessive soap
Fair _ Overflowing _ Sand
Poor _ Blockage _ Repairs Needed
Very Poor _ Odor
_ Roots _ Mo fr quent service needed
No one home Total amount due Total billing to
Signature 14Z��� or above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work
TOTAL PUMP
DISPOSAL FEE
TOTAL LABOR
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
v
D OM LETED
D
WORK RED BY
TOTAL AMOUNT
'
$
No one home Total amount due Total billing to
Signature 14Z��� or above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work