0401-207 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby aff'rm undo 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
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:
94 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 ' l r Signature of Owner 1"._
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 S T T 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 those provisions.
,Date: / c'rC Applicant
i
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 property for inspection purposes.11 / !�
Signature (Owner/Agent) 4 �f •r �'—' Dater
�. E`,x1DING PERMIT tel` KIM ITJ1 I
DATE ,C.,:r �` VALUATIONy� LOT TRACT
JOB SITEt-
ADDRESS 52-S&I A INN10A V[TA,A
APN
773-303-015
OWNER ,
CONTRACTOR/DESIGNER/EN (NEER
HON0147i.E: & Kly. AFAN
OWIMR. BI ilLPYR
52.553 AV 111D 1.VILIA
LA QUiNTA CA 9225.3
USE OF PERMIT
PLiT.M.#�113C
SfeWER COWNFCT.SFP 'IC A23.AWD0NZMSNT
VAMI.ATION 1,800.0011
E t MA3TMD COWT Olt' CO..^i:MITME; N
I.'800.0D
Pt E12MiI'T�'FF 'lviATt�I
PI.ttI►ll D40 FEY, -- SIDWER 101-000-419-000 %30.00
SUB -TOTAL, COlNYSIRUC'1ZON AND PLAN L41 ECK
$30.00
LESS PRE-T'AM F � S
TO.00
D 11110 , in O.S.01JL NOW
00.00
JAN 15 2004
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT DATE - BV • r
DTE FJNALED
INSPEC
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
s
Equipment Location
Underground Electric
Underground Plbg, Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
' later Piping
Plumbing Final
'umbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lo%VVoftage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COACHELL
_1_,RY WATER DISTRICT
CASH RECEIPT DETAIL ?&TQi 001 AR
These deviations from the drawings of record are beyond the control of I
CVWD; therefore, Ihe district will not be responsible for any charges
incurred by the homeowner as a result of these inaccuracies. ti
July 1, 2002
Receive rom* A
.-S
CIL\'
Address t
Accoun o. J Lot(s)
Tract
Service dres,
G.A. Code
0 met
$
_EI Service(s)
0 Backflow(s)
f 0 House Lateral(s)
0 Detector Check(s)
0 Meter Surcharge
• '�S�nitatlon Capacity Charge
• W.S.B.F.C.
• Temporary Construction Meter
• Turn on Charge
(D Uncollected Account -Name
• Inspection Fee -Tract -
Fee -
• Plan Check Fees Water Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
• Customer Deposit
• Other
TOTAL
$
f
Remarks:
ct kj- Q -c -CA
ucpy'to: ti
'6 A
Cash
Water Service
k
YrCashier
Or
Orderr
CVWD-438 (11189)
drawing ofrecord.
These deviations from the drawings of record are beyond the control of I
CVWD; therefore, Ihe district will not be responsible for any charges
incurred by the homeowner as a result of these inaccuracies. ti
July 1, 2002
��
VALLEY WIDE PUMPING SERVIC
"Your Waste Is Our Problem"
JOB INVOICE
1 V V J. JUI If ise VVdy JUILC 1 JJQUSTO
PALM SPRINGS, CA 92262
(760) 322-2400 (760) 347-3545
ER'S ORDER NO. DATE ORDERED
—
ORDER TAKEN BY DATE PROMISED O A.M.
❑ P.M.
BIL T PHONE
AD RESS ME NIC'
IT S/ HELP 72M.
IM
JOB NAME AND LOCATION -
❑ DAY WORK
0 CONTRACT
aD SCRNOF IPTI WORK
-�
P 126,9,4e -,V, 42 —JT
❑ EXTRA !`
f v YI'
G Jac
n �
ti
QUANT.
ESCRIP ON OF MATERIAL USED
PRICE
AMOUNT _
Gallons f 6'- 1 " ^ 00,04,- 100 0 0,5/
40,50---1/,-0'
n
�y
1-
r
Pumping Fee per 1000 gal.:'
Dumping Fee per 1000 gal.
Out of Area Fee I'
3
Locating / Opening Fee (per hour)a
Size System:A Cre L"
ri
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 11/2% PER,MONTH, 18% PER YEAR
WILL BE CHARGED ON''PAST DU5 ACCOUNTS OVER 30 DAYS.
HOURS
ILABOR / / AMOUNT
TOTAL
MATERIALS
MECHANICS Q
TOTAL
LABOR
r r
HELPE S �J@ i
I hereby acknoyAve dg' he satisfa¢�ory /
completion oflthe a ve descs $d work/'
TOTAL LABOR
TAX
SIGNATURE J
/f{e.
DATE COMPLETED
TOTAL
pp
To Roorder Cell NEBS CUST&M"printing service TOLL FREE 1-800.888-6327
NEBS, Inc., Peterborough, NH 03456.
Ret, No: G 710703566
NOTICE TO OWNER
I' Under the California Mechanics Lien Law any contractor, subcontractor, laborer, supplier'
,or other person Who helps to Improve your property, but is not paid for. his/her work or
5 supplies, has a right to enforce a claim against your property. This means that after a court
hearing, your property could be sold. by a court. officer and the proceeds of the sale used to
ssatisfy the indebtedness. This can happen even if you have paid your contractor in full if the
ubcontractors, laborers or suppliers remain unpaid.
r To preserve their right to file a claim or lien against your property, certain claimants such
,,,its subcontractors or material suppliers are required to provide you with a document entitled
� 'rellminary Notice." Original (or prime) contractors and laborers for wages do not have to
de this notice. A Preliminary Notice is not a lien against your property. Its purpose Is to
Jr rf'otify you of persons who may have a right to file a lien against your property if they are not
paid. Generally, the maximum time allowed for filing a claim or lien against your property is
ninety (90) Days after completion of your project.
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY,
YOU MAY WISH TO TAKE ONE OR MORE OF THE FOLLOWING STEPS:
1) Require that paymerlts be made directly to subcontractors and material suppliers through
a joint control. Any joint control agreement should include the addendum approved by the
Registrar of Contractors.
2) Issue joint checks for payment, made out to both your contractor and, subcontractors or
material suppliers involved In the project. This will help to insure that all persons due payment
are.actually paid.
3) After UPON making payment on any completed phase of the project, and before making
any further payments, require your contractor to provide you with unconditional lien releases
signed by each. -material supplier, subcontractor and laborer involved in that portion of the
work for which 'payment was made. On projects involving improvements to a single family
residence or'a duplex owned by individuals, the persons signing these releases lose the right
to file a claim against your property. In other types of construction this protection may still be
Important, but may not be as complete:. TO PROTECT YOURSELF UNDER THIS OPTION YOU
MUST BE CERTAIN THAT ALL MATERIAL SUPPLIERS, SUBCONTRACTORS OR LABORERS
HAVE SIGNED.
r
Jan 15 04 01:09p p,1
A I I state®
You're in good hands.
5722SS1 V5R2M0 0207Zgint Key Output Page 1
A400008001/15/04 12:56:58
Display Device . . . . QPADEVOIRD
User . . . . . . . . . . : SCAA9807
Insured: HONOFRE G AFAN & KIMBERLY A AFAN HW Fol No: 099668863 09/21
Address: P 0 BOX 586 City: LA QUINTA
Home: ( 760 ) 564 - 4233 Zipcode: 92253 - 0586 Org Year: 89 Agent: 41A72049
Class 5501306 **PROPERTY SUMMARY**
Status ACTIVE POSTINGS Clms: N Frms: Y Dsc: Y
Premium: $748.00+ RENEWAL PREM 090903 $748.00+ Pay Pln: NO PLAN
AAP $748.00+ CASH -LIST BILL 090903 $748.00- Nxt Due: $0.00+
Balance: $0.00+ RENEWAL PREM 090902 $689.00+ B11 Act: FOLUP ISSRN
Lst Bll: $748.00+ CASH -LIST BILL 090902 $689.00- On: 9/27/04
Cur Due: $0.00+ RENEWAL PREM 090701 $572.00+ ALL 'ERILS $250
Due On : 9/06/03 CASH -LIST BILL 090701 $572.00-
Pol Type: DELUXE HOMEOWNERS - PRIMARY RESIDENCE
COVERAGES LIMITS PREMIUMS DEDUCTIBLES
BASIC COVERAGE 1,277 $3.00
-)BASIC COVERAGE 137,369
?WORKER COMP -OCCASIONAL CLASS $73-_.00
REPLACEMENT COST CONTENTS $9.00
BLDG STRUCTURES REIMB EXT LMTS $0.00
$0.00
(ENTER) CONTINUE} (F1) HELP (F3) QUIT (F4) BACK SCREEN
(F9) VIEW BILL �F10) RESCAN
LAST
R2853-1