0108-222 (PLBG)LICENSED CONTRACTOR DECLARATION
I h(Aeby 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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Dateex""'1' � de;'lSignature of Contractor/" t�:✓
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. /U44, HUsiriess & 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:
( ,) 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.
$1.eliTLf FUX1,4 D INT 1-0i
(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 shalt forthwith comply with those provisions':
Date: J 1 _' Applicant -
,J ?'
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
.addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person,at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propertyfori9spec lion purposes.
Signature (Owner/Agent)' Date4' `
s
BUILDING PERMIT PERMIT#
DATE VALUATION LOTp. •'% TRACT
JOB SITE APN
ADDRESS
;245 W�,�S+$'MOM 110 DRIVE
OWNER CONTRACTOR / DESIGNER / ENGINEER
f
80.245 W%&MAM)1i01)3tTir~Jk 84035 CABAZO14 ?;I3, I�aD10, 4;�f9 '�2�' 01
LAQU�1`a:i:'�!.... PALM I: FZF-€. CA 92261
(7t�4i9'a•Rli-7r`fi93 %Lif- 34.aN
USE OF PERMIT
i"
S p a aelv�s Sser,3; ye iva1'ac?et
VF`�Jt,`�'IED C,'O,') '—r OF CONST'1.tfTM1011
15:f� 1�i1V�;1 FER -- UMM. 1014.100-419- 000 SX0
4
D a �
AUG 2 3 2001
CITY OF CE
PQUINTTA
2,150,00
180.9 P.RB-PAID RUMS $0.00
prismTkIE ifs ME NOW
RECEIPT DATE' gg BY DATE FINALED INSPECTOR
lk
11 .X
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
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 Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final I
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
Water Piping
Plumbing Final
PlumNng Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral/�/
Sewer Connection �fl Z�`
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) wl
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:
_
45-500 Van Buren • Indio, CA 92201 • (619) 347-2356
SEWER CONNECTION PERMIT
N? 2002
WAM
F.1Addition
New Construction ........
❑
=' - .
Date:--),
' ,
-
......
Annexation No.
FEES
Repair/Alteration ........
.
U.O.S.
Parcel No. -
Owner:
Total
Due
Contractor:
Connection: ......................
Project Name:
$ ;i _ _
$
License No.:
Project Address:
i -`l.
-� iU
Phone No.
Comments:
C-6 v\ -'LT i Cts
' Principal Lateral: ..............
Applicant Signature:
Issued by:
=' - .
Date:--),
l
-
FEES
U.O.S.
Rate
Total
Due
Paid
Connection: ......................
X
$ ;i _ _
$
�'-'r. �.
❑
Inw pect'ion:
' Principal Lateral: ..............
x
$ _
$
❑
❑
Subsidiary Lateral: ...............
x
$ _
$
❑
❑
Saddle:. ......:.... .... .
x
$ _
$
❑-
❑
Disconnect : ............. ...
x
$ _
$
❑
❑
Addition:.. ..................
x
$ —
$
❑
❑
Repair:............ ... ...
x
$ _
$
❑
❑
Other:
x
$ _
$
❑
'❑
TOTAL FEES:.
$
7.—
Receipt Nc.
INSPECTIONRECORD
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. 3 . .
Signed: Date:'
WHITE — VSD CANARY — Annexation File PINK — Permitee
EC SEWER SERVICE, INC. - J00 MORE ORDER
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261 ^ .14 9 81 `'"'
17m say-27a� 17an► -q2R-77an
FAX (760) 347-4978
DA F ORDE�j
SERVICE CODE
PHONE -
TECH N
HELPER
STARTING DATE
BILL TO
TYPE OF WORK
�.�
❑ CLEAN DRAINS
❑ OTHER
ADDRESS
K
--K� 1"4'11se z
❑ SEPTIC TANK
CITY
❑ GREASE TRAP
OL «/
❑ SEEPAGE PIT
JOB .NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERMS NFZ10 DAYS FROM DATE OF SERVICE 11/2% PER MONTH CHARGE AFTER 30 DAYS.
� l g
DESCRIPTION OF WORK:
'n _ f A _
v-
0 ITION OF TANK BEFORE SERVICE
Good _ Trash 8 Garbage _ Excessive soap
_ Fair _ Overflowing _ Sand
_ Poor _ Blockage _ Repairs Needed
_ Very Poor Odor
Roots More fr ent service needed
/"r ❑ No one home MTOtal amount due ElTotal'billing to
jrSignature for above work: or be mailed after
h y acknowledge the satisfactory completion completion
I
of work `
of the above described work.
TOTAL PUMP
DISPOSAL FEE
TOTAL LABOR
LEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS'
D OMP -TED
WOR RED BY
TOTAL AMOUNT
$
/"r ❑ No one home MTOtal amount due ElTotal'billing to
jrSignature for above work: or be mailed after
h y acknowledge the satisfactory completion completion
I
of work `
of the above described work.