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0105-038 (PLBG)M Ln N ON 0 °' CL Q Lo Q 0 Lu LL 0 J J mVU O � LO It Z r- d LICENSED CONTRACTOR DECLARATION 1 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 H'/ofes'sionals Code, and my License is in full force and effect. .ZLicense,.1 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: ,(Xc I, as "owner of the property, or Imy 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.ifor this reason.f + Date �U,f' d Signature of Owner I, , ."o".' t; WORKER'S COMPENSATION DECLARATION I• he eby 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 with those provisions. _I Date: Ar, . < t n i Applicant, s`%a:. .r :�'.9 A A-41 Z ., , ..,... , / �... .... /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°inspecttiion purposes. ) Signature (Owner/Agen j,J'��>'rt��* �' Date-�d BUILDING PERMIT PERMIT# DATE VALUATION LOT 01MQi'«10 TRACT IONOM JOB SITE APN ADDRESS OWNER CONTRACTOR // DESIGNER /ENGINEER SAMppA T,HARJ1140 OVFw?{iMMER 79.75;5 F0 OTA DRIVE ui. Qowv%, OA 92253 USE OF PERMIT i}r�.•ia'i'i�. TA3�k;:.f.A'F.I'f�Y • �•a ��':i�. @�lt.St�X�:'U? VA1TJ.rst'IION n%000.4t) 1.1 .= co W7 O:Ei+,' C"-0M1rr;?1*0'3'`.':l:if3N �Rkry1 .A� :C...J.GdF!AA..�m.A'.YP�� dD YI.��:i,6�J,.�•kK� 230.00 W D MAY - 4 2001. CITY OF LA OUINTA FINANCE DEPT WXR-itYM .0O.NYCRUTC:310.14AMPLAI%1; G,-Ml"K p3t3.!�q T(Y)"AL r Elah 1f , F"M syli.t l?0'W RECEIPT DATE_ / BY DATEFINALED INSPECTOR a TC:a 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 Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans_ _ Sewer Lateral W` Sewer Connection Gas Piping O.K. for Finish Plaster Pool Cover Encapsulation 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) COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL 0 8 0 Received From: Ls 'ICAR. Address: "15, L—a- tt Account No. %Lot(s)_ Tract Service Address G.A. Code p. 0 Meter(s) $ • 0 Service(s) 0 Backflow(s) 0"House Lateral(s) .0 Detector Check (s) 0❑Meter Surcharge 4r Sanitation Sanitation Capacity Charge 0 W.S.B.F.C. 0 Temporary Construction Meter 0 Turn on Charge 0 Uncollected Account - Name t. 0 Inspection Fee -Tract - Fee - 0 Plan Check Fees Water I Sewer - Tract - 0 Bond Payment - A.D. --Bond Assmt. 0 Customer Deposit 0 Other Remarks: 0 COPY to: Cash Check 1- 3 t4 0 Money 31 Order TOTAL$ '4 o WaterService". Cashier 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. Foi your protection you should be aware that as "Owner/ Builder" you are the responsible party of record 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 proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and 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 $200.00 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, worker's compensation insurance, disability insurance costs and unemployment 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 worker's compensation insurance. Fqr more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if `+ you wish, the U.S. Small Business Adminstration). 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. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, CA 92253 (760) 777-7012 766)777-7011 W DOWNER'S SIGNATURE/DATE PROPERTY ADDRESS PERMIT NUMBER(s) XCE � • Ti _RED O dISED [] A.M. L7 P.M. � 1 J DAY WORK L' CONTRACT I El EXTRA QUANT. DESCRIPTION OF MATERIAL USED PRICE, AMOUNT Gallons ,Pumping Fee per 1000 gal. 5 / f umping Fee per 1000 gal. e— Out of Area Fee Locating / Opening Fee (per hour) .�., Size System: A SERVICE CHARGE-OF•$20-WILL BE DUE ON ALL RETURNED CHECKS. 18% PER YEAR WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS. HOURS LABOR AMOUNT TOTAL MATERIALS MECHANICS Q I HELPERS Q TOTAL LABOR N I. erebyacknowledge the satisfactory TQTAL 9608 pletion of thea ve described work: TAX N T RE II I n, DATE COMPLETED TOTAL jC/ 54 co Z O U W rn U) Y tr Q W tr U L" U) n 1��' tG � ,. . i.. .4~1 :�ri ati � ,.HtyiZ fr•,.tj 1• r�� .. +` ., � J•` r * .o , r COUNTYF RIVERSIDE, _/0_00/ SUBSURFACE PERMIT APPLICATION TION FORENVIRONMENTAL A SEWAGE DISPOSAL SYSTEM Applicant: Submit this form with four copies of a scaled plot plan (1.20 scale) drawn to County specifications required on the attached check list. A non-refundable filing fee of $40 is required when the application is submitted. Check must be made payable to the County of Riverside. Building Department Application Log # Name (Ow Contractor,- tc I Mailing Address 'r�Agent 1, '� �,Grt State Zip Code Telephone -Job Properly Address r 1Arrn -_151. 'Gty- r. Cor9irtionoy Le I Description of Property (Lot. PM. TR) a T •Assessor's Parcel No Iwater Agency oc_:1Mefl*�'�. �� ` use of Permn �&I"dge" laIn ng Case M (-2,02G asr,r,..t Lot Size It jX/ MH Site Preparation Etc SFD. -,Signature of AppliCani -- Dale - /' ._ •The above information must be verified from Building Application / STAFF USE — DO NOT WRITE BELOW THIS LINE X'Initi//all Date Existing S.D. System ❑ Yes ❑O No �.(,.�!& Q, - 2. 1 " Certification of required. ,� WOCB Clearance required. ❑ Yes 2 NV i Soils feasibility report required. ❑ Yes Special feasibility boring report required. ❑ Yes ❑ jNb Detailed contour plot plans required. ❑ Yes © .No Staff Specialist approval required. ❑ Yes lJ No Lot Inspection Date Soils/boring report by Project # Date • Soils Map Page/ ( Soil Type AD Approved by AW/1 n f Type of System: " No. of Bedrooms(1) Septic Tank Soil Rate Required0�1 , ❑ Existing PrNew ❑ Additional ❑ Replacement s, Gals. �,(J //00_ave, (2) Leach line sq: ft. Sidewall allowance Install-—Line('s7 Ft. Long, v Leach. bred Sq. (Bottom trench area) ft. rock/ Sq. Ft. 3 Ft. wide with min. /inches Ft. of bottom^ iye n, / - _ per running ft. ❑9'N%A rock below drain lines area Leach lines/beds pkiial design for slope: Applicable ` (3) Pit Diameter No. Pits `�, Pit BI �^,,.,� Seepage� Pit total depth Ojverburden factor ❑ ❑ 6' 5' Max. allowable,depth �NJ//A 1 / A. 7�f YY Ct-x7 _` L.� � Y_.r,_/ �..•' i7�+ pi� �a.C�'' �• �/-•f� y!�/iir s,.._ �(t� U�j/t�v ./�iL��C.I�( (/*lG..� ii'L_ � �.j'�'f. �..%%�r4��.�' / �¢ •{i l��P GCi�tn h i�lT.��v-�. rte,.•,. .0•1.4 i.t l't'wC .16 cx~"r¢iG+•-� A /fi�••�,�r, °�c.c-r a'� .%�" +�j � %'rte' �e`�•`''r"g� �t..PI..K�?-t„=-e ���... /S� /T / This applica Ion is app d/ . taied.for the design of'a subsurface disposal system as Indicated on the accompanied plot plan using therequirements set forth in Section B above. A building permit is necessary for the installation of the above -designed system. r 1 �om any wells/Af -ce�i> 4 LIJ�'.r�-«•r S h (C1)1�! Septic tank and sewer lines must be 50 fri" &)2 Leach lines must be 100' min. from any wells including expansion area ✓�" 'rs GuCep�,, f'i 1".�` (3) Seepage pits must be 150' min. any wells including expansion y from pared Ell �"" �T4, tt 6r ...e.+f .At Mr. SignatureofHealth Official �(,iRt!G�•O Date6 ,/��., `� �� 16-1 RECEIPT NO. � Issued by S�C �"" �" Date 44 - I/� District: ❑ Riverside .O Indio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe Distribution: WHITE—Office file YELLOW—Applicant PINK—Bldg. Dept. GOLDENROD—Pending File DOH SAN 122 (Rev 8/87) 7 ci IM