0301-250 (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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
746l59 C421110 W.` N
Date r '? Signature of Contracto!7—
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 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 STA i t? FUND Policy No. 077221-02
(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 those provisions.
Date: r. �� Applicant
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 pernn at
whose request and for whose benefit work is performed under or purs to
any permit issued as a result of this applicaton agrees to, & shall, ind
& hold harmless the City of La Quinta, its officers, agents and empl s.
2. Any permit issued as a result of this application becomes null and i if
work is not commenced within 180 days from date of issuance o u h
permit, or cessation of work for 180 days will subject permit to canceUlatiI certify that I have read this application and state that the above inform
correct. I agree to comply with all City, and State laws relating to the b
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) J - — + ` r Date/
BUILDING PERMIT PERMIT#
+S3Cl t 2N)
DATE.l71A0 VALUATION as `,tfvtbd� LOT y TRACT
JOB SITE
ADDRESS N2-6)1 1 A V .MA. VW....A. APN
OWNER CONTRACTOR/DESIGNER/EN &NEER
AR401M IMS NANM i-�C()N0 8EWF- TC :.°k RV1,CL
52.611 A'JFNM k VILLA LA 16819 L T'r11.3 i MQ1ZG 3 U 0 1 W
1 (,�iJIN1i4Cts 2ZS3 Af0RT11331ALM,;A)R K, t' A 992256
(70)):346-2793 CRI -di 1442
USE OF PERMIT
C
VALUATION
Z009 00 114-1
FS"1It+EA' KII C011131r (V C-ON17FRUC'Y10N
Pls.'kA4Tt'FFS is't. MMARY
PUINIDIN0 FELT -- SEVER 101-PI01• 119 -ow
ea,vTAT CC31�i"w`T"itM(.710H AND 11"i -AN (`FWCK $34.00
Ix93 FA)M-PAR> 11MZ' s"O.00
N 2 1 2003 TMAL PTI MIT.11YUs DITf;1' NOW S.''-1 AYP
OF LA QUINTA
IANCE DEPT.
RECEIPT I DATE I BY I DATE
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL
APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
92-f�s
Final
COMMENTS:
Final , O.
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
rJl! l.;/ [elr7.i U4: ji j !605642955
PAGE 01
COACHELLA VALLEY WATER OISTRICT
CASH RECOPT DETAIL 93075
Received From.' �1..
' Date•
AF
��-
Service Address _� i � t � L t � �'� (�' t� C � t,{'t G.A. Code
0 Meter(a)
4 serricera)
Cl Saekflow(s)
C House L ZArei(s)
O DetectorCheck(s)
0 ��Mootrtor Surcharge J
�TSanitatlon Capacity Charge
❑ WS.B.F.C.
Q T sr7sa;y {:isiPid iKr.^... oto-
❑ Tum on Charge ,}
O Unealected Agcount - Name 1!
O Inspection Fee - Tract -
Fea -
M Plen Check Faee yJnier 7 :;_Zewe -
Tract -
O Bona Payment - A.D.
Asamt
O Customer 06pQeIt - JJJ
El Other
.1
TOTAL ti _i/ /.r� •� 9
Remarks;
r
0copy to:
CCane k r-'. ,:, Wate►$ervl� t��
ManeY
Order A -Cashier_
- - .3i=.
i
1R,.. t � 3 I •l
lip i: .
• r ,
' jnN-20-2003 MON 09;0—, 1-1 TT[)
EC Sewer Service, Inc:
dba. ECONO SEWER SERVICE
P.O. Box 581029, North Palm Springs, CA. 92258
(760) 346-2793 (760) 328-7760
Fax (760) 251-3405
JOB TICKET
ADDRESS TECHNICIAN
CITY , HELPER
JOB ADDRESS S)--
6//
TAV& Y171,09
q
GA QUi,✓1 i9
SERVICEC SEPTIC TANK RAS SEPTIC TANK BEEN DUG UP? ❑ Yes ❑ No ❑ MT. ON SITE
REQUESTED - r PUMP SEEPAGE PIT AT ITS RISER EOFEIC* BILLING
❑ PUMP GREASE TRAP [TYellow Cua.
❑ OTHER ❑ Yellow Office
QUANT. DESCRIPTION OF PRICE AMOUNT
Ld
3voc)
Pumping Fee per 1000 Gallons (or fraction)
o a
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee (I hr. Min.)
Out of Area Fee
PuA►P S�`r
ON 9 A/1a3
GREASE TRAPS
❑ RECOMMEND INLET/OUTLET/BAFFLE REPAIR
❑ EXCESSIVE GREASE/FOOD/DEBRIS.
EXCESSIVE ODOR.
RECOMMEND MORE FREQUENT PUMPING.
❑ RECOMMEND LINE CLEANING.
SEPTIC SYSTEMS
❑ THE LEACHING SYSTEM HAS FAILED.
❑ THERE IS AN OBSTRUCTION "UPSTREAM" OF THE SEPTIC TANK.
It will be necessary to contact a line cleaning company.
❑ WE RECOMMEND MAINTENANCE PUMPING OF THE SEPTIC TANK EVERY
❑ YEAR ❑ OTHER YEAR ❑ 2-3 YEARS
To remove built up solids. This will increase the life of your leaching system.
❑ THIS PUMPING WILL PROVIDE ONLY TEMPORARY RELIEF AND NOT
SOLVE CUSTOMERS SEPTIC PROBLEM BECAUSE OF THE ABOVE.
❑ CUSTOMER HAS BEEN GIVEN AN "EXPLAINATION' PACKET.
A SERVICE CHARGE OF S22 WILL BE DUE
ON ALL RETRUNED CHECKS.
A FINANCE CHARGE OF 1 1/2% PER MONTH, 18% PER YEAR, WILL BE
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
U? PAYMENT IS BY CHECK
DRIVERS LIC. # STATE
1 hereby acknowledge the satisfactory completion of the above described work:
SIGNATURE
/
Total
Due
-
� r
9
NOTICE: THIS IS NOT A BUILDING PERMIT
APPLICATION TO CONSTRUCT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF RIVERSIDE
DISTRICT r +
Permit
284 199 9/74 CANARY—FILE, PINK—APPLICANT
Architect Con tractcr111A.,#_ ./n< -
1
AddressL 2 `/ % e, _/`B�-
Address �—
A
City i_ ` City Cit,�iJ"?_�_--e;.
Phoneme �a Phone Phone
I (we) the undersigned, hereby certify and acknowledge that I (we) have read the application and agree that if Curb and Gutter, and
W
Z
Paving, and/or Dedication of right of way is required by the County of Riverside, the Riverside County 'department of Building and Safety
3
shall not make a Final Inspection until said requirements have been met. I am also aware that no work is to be done within the County R/W
O
without an encroachment permit.
NOW, therefore, it is agreed that I (we) will not occupy said property and will not cause said property to be occupied until I (we) have
complied with all laws of the County of Riverside and the State of California governing said property.
^
t
DATE ��\C f SIGNATURE OF OWNER AND/OR AGENT •
Approval by Signature how the Following Departments Li d Below
Must Be Obtained Prior to the Issuing of a Construction Permit.
I SPACE N0.
— % ' / 1 USE OF STRUCTURE
04�
JOB ADDRESS �� �� / � 4� ✓
SINGLE FA..IILY�}"' DUPLEX El
W
.��
LEGAL D SCRIPTIO OF PROPER ��C -,T APARTMENTS /o[] AGRIC. El
O fill.
N QCOMMERCIAL
�_
E] INDUSTRIAL L,
'^
C
COMMUNITY "'
f� ALTERATIONS []
C
Z
NO. OF SUBMITTED PLANS — USEF OPERMIT
CASE N0.C all 4J
Z
NO. OF PARKING SPACES REQUIRED —_� N0. OF 1306INGS NOW EXISTING -
a
ZONESETBACKS: FRONT SIDE REAR
m
GRADING PERMIT REQUIRED? YES ❑ NO ❑ LOT SIZE
SETBACK ORDINANCE II _— OF FEET REQUIRED ONSTREET
DATE— — SIGNATURE OF LAND USE OFFICIAL r.,
DEDICATION REQUIRED: YES ❑ NO ❑ NO. OF FEET—
uZi
CURB AND GUTTER REQUIRED: YES ❑ NO ❑ STREET
i
oc
i
CAN CURB AND GUTTER. FEASIBLY BE INSTALLED? YES ❑ NO ❑
W
HAS AN ACCEPTABLE APPLICATION BEEN MADE FOR ENCROACHMENT PERMIT FOR DRIVEWAY AND STREET
CIMPROVEMENT?
YES ❑ NO ❑
of
DATE— SIGNATURE OF ROAD DEPT. OFFICIAL
_
SWIMMING POOLS PUBLIC
SEWAGE DISPOSAL
_
FOOD ESTABLISHMENT
WATER POLLUTION REMARKS
�n FLOOD CONTROL—
z AIR POLLUTION
W
t -DIV OF HWY
c % — YOUR PROP'=RTY MAY BE SUBJECT TO
0
c FLOOD. RI'VERSIDE COUNTY ASSUMES
NO RESPONSIBILITY IN EVENT OF FLOOD.
284 199 9/74 CANARY—FILE, PINK—APPLICANT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF RIVERSIDE
OWNER -BUILDER VERIFICATION
ner
Address
An "owner -builder" building permit has been applied for in ycur name and bearing
your signature.
Please complete and return this information in the envelope provided at your
earliest opportunity to avoid unnecessary delay in processing and issuing your
building permit. No building permit will be issued until th-s verification is
received.
1. I personally plan to provide the major labor and materials for con-
struction of the proposed property improvement (yes or no)
2. I (have/have not) signed an application for building permit
for the proposed work.
3. I have contracted with the following person (firm) to provide the pro-
posed construction:
Name Phone
Address - City
Contractors License No.
4. I plan to provide portions of the work, but I have hired the following
person to coordinate, supervise, and provide the major work:
Name PhonE
Address City
Contractors License No.
5. I will provide some of the work but I have contracted (hired) the fol-
lowing persons to provide the work indicated:
Name Address Shone Type of work
Signature Property Owner
Social Security Number
284-2002 7/80
Date
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF RIVERSIDE
OWNER -BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder
of the property improvements -specified.,.
For your protection you should be aware that as owner -builder you are the responsible party of re-
cord on such a permit. Building permits are not required to be signed by property owners unless
they are personally performing their own work. If your work is being performed by someone other
than yourself, you may protect yourself from possible liability if that person applies for the pro-
per permit in his or her name.
Contractors are required by law to.be licensed and bonded by the State of California and, where
required, to have a business license from the city or county. They are also required by law to put
their license number on all permits for which they apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract,
you should be aware of the following information for your benefit and protection.
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is $200 or more for the entire project, and such persons are
not licensed as contractors or subcontractors, then you may be an employer.
If you are an employer, you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal
social security taxes, workers' compensation insurance, disability insurance costs, and unemploy-
ment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these' -risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law, contact the Internal Revenue
Service (and, if you wish, the U.S. Small Business Administration). For more specific information
about your obligations under state law, contact the Department of Benefit Payments and the Division
of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed
to perform their work personally or through their own employees, without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "owner -
builder" building permit, erroneously implying that the property owner is providing his or her own
labor and material personally. Building permits are not required to be signed by property owners
unless they are performing their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors'. State License
Board in .your community or at 1020 N Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that
you are aware of.these matters. The building permit will not be issued until the verification is
returned.
Sincerely,
DEPARTMENT OF BUILDING AND SAFETY
Leopoldo Rojo, Jr.
Director
284-2001 7/80