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LICENSED CONTRACTOR DECLARATION
"hereby affirm under penalty of perjury that I am licensed under provisions of
ihapter 9 (commencing with Section 7000) of Division 3 of the Business and
--Professignals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
746159 C42
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 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 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 With4hose-provisions.
Dates 4- r Applicant
Warning: Failure to secure Worke'rs' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
'Signature (Owner/Agent)-` ^✓frµ� . Date4i'
BUILDING PERMIT PERMIT//
DATE _ VALUATION LOT 0107..004 TRACT
1M.1C3iS1M
JOB SITE
APN
ADDRESS
79-7YMSTA.8MVP
OWNER
CONTRACTOR / DESIGNER / EN (NEER
IvM SANYA CITaq
RC(33140 ISk 1F'RWOM
I-180FI&M.AlYRIVE
811035 Q--6 ZON71. '1 WDY), C.A92201
1A Q1,7QTfA CA 92.253
P Ai..M"ar�°'.`a'rY,�,�.1 CA. x12261
(760)346-2793 rMlif 3-0
USE OF PERMIT
SEPTIC TANK A;3ANOMM01Z, S��'ti ER kiOOK-OP
�
VALUATION �,l �p.aq i,S
r
KN AT" C. 08T OF V,01,14 E'f17M1:0N
711W.0t)
,..
FR0.WRE M$UyY
P1,11 XU SINO PRE — MINER 10 t -000.4) 9-000
AND PLAN' ):, AN CHi3.,M,
S -10.00
Dw ESS P1MPJgD F
V0100
J U L 2 2001 . � � . , ��ax� ���� �a�r.�� ���:►�►
����,��
CITY OF LA QUINTA +
FINANCE DEPT
RECEIPT DATEBYE t p D My INSPECTOR
t
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
F DATE
I 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
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_ _
Sewer Connection
Gas Piping t7— ,
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)
EC SEWER SERVICE, INC.
dba ECONO SEWER SERVICES
F.O. B0)( 192 • PALM DESERT, CA 92261
(760) 346-2793 (760) 328-7760
FAX (760) 347-4978
JOB MORE ORDER
14849
DATE OF RR w '
-9'-0/
SERVICE CODE
PHONE
TEC IAN
HELPER
STARTING DATE
BILL TO
TYPE OF WORK
�S ti
❑ CLEAN DRAINS
❑ OTHER
ADDRESS
TOTAL MATERIALS
r
DATE COMPLETED
r
TOTAL AMOUNT
❑ SEPTIC TANK
❑ GREASE TRAP
CITY
❑ SEEPAGE PIT
JOB NAME AND LOCATION
ADDITIONAL WORK NEEDED:
TANK SIZE:
PAYMENT TERM,$.lN�T 10 DAYS FROM DATE OF SERVICE 11/2% PER MONTH CHARGE AFTER 30 DAYS.
: j
DESCRIPTION OF WOR n ` n /
17 — C9PDITION OF TANK BEFORE SERVICE
_ Good _ Trash & Garbage _ Excessive soap
Fair _ Overflowing _ Sand
_ Poor _ Blockage _ Repairs Needed
_ Very Poor _ Odor
Roots _ More frequent service needed
❑ No one home tal amount due ❑ otal billing to
Signature for 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
DATE COMPLETED
WORK ERED BY
TOTAL AMOUNT
$
❑ No one home tal amount due ❑ otal billing to
Signature for above work: or be mailed after
I hereby acknowledge the satisfactory completion completion
of the above described work. of work
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From: 1---f / 1,L. 1\1 1"', A, /1,; �fzn ✓/% r A Date -
Address:
Account No. (11_ Lot(s) Tract TC3
Service Address 7-) i G.A. Code
• Meter(s) $
• Service(s)
• Backflow(s)
• House Lateral(s)
• Detector Check(s)
0 Meter Surcharge
P --Sanitation Capacity Charge
0 W.S.B.F.C.
• Temporary Construction Meter
• Turn on Charge
• Uncollected Account - Name
• Inspection Fee - Tract -
Fee
• Plan Check Fees Water / Sewer -
Tract -
• Bond Payment - A.D. --Bond
Assmt.
• Customer Deposit
• Other
TOTAL
Remarks;
Co.— to:
Water Service,
Cdshi
CVWD-438 (11189)
Cash
Check
Money
Order
Water Service,
Cdshi
CVWD-438 (11189)
ALLEY WA ER DISTRICT T.F COACHELL
ii-7i LA. CALIFORNIA 92236
1 3 9 8 2651
ACCOUNT N'j."ER DATE
2
INVOICE rya.
r jUE. A -NO PAYABLE ON RIECEIPT
AMOUNT DUE
THIS INVOfCE
F - 1-10 AOX (-;,,DACHEL.!.A, CAL�FORmA
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