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0107-002 (PLBG)H N_ W .. O'er c7 f ` d LO o Z CCD0O I— cD J Wr` W U) Z LO CV ON U °) C1. Q Z Lo a 0 LL Q J J mUU O d rn H Z 0 5 CY Q J 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 i46159 C42 k33,� _--- � : •- ` L'l��.e s,�2f patef--_ 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 with those, provisions. D'ate:~ y Applicant";'- Warning: pplicant;'-_Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. 1` Signature(Owner/Agent)',r - :Date BUILDING PERMIT PERMIT# BATE VALUATION LOT 01 TRACT JOB SITE APN ADDRESS OWNER CONTRACTOR/DESIGNER/EN INEER 79.,605 F'.P".�$i'ADRIV 04W5 C fiZ-0N RD, WID10, CA 92201 P, QWW'A SCA 92253 PALJA D&STRr CA. 92261 (760)-446-2793 CMEZA :342 USE OF PERMIT ,91STW,C41. Q. eiJ C091' ip.6: GvOdV d7. LF 4'e ItirJX 2. RW.Vol MAST Foil SUMMARY � PLLrNIBINO kt`L 4 •- 39M. 1020004 3 94M S 6t,Gfa 1X33 P11TR.-PAW P1723103 Ii $01W _ I J U L 2 2001 `.b IWMI971S rs M, CiTY OF LA OUINTA FINANCE DEPT f m) RECEIPT DATE BY DATE FINALED INSPECTOR v INSPECTION RECORD a' OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air +a' Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans 8 Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final 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 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� Gas Piping 6 INKV Gas Test Encapsulation Appliances Final Final � 0 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) COMMENTS: COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL Received.From: '�-�� v Y� .� r, 9,.--1l Address: Account,No. , . • Lots) — Service Address ❑ Meter(s) ❑ Service(s) ❑ Backflow(s) House Lateral(s) Q ❑ DetectorCheck(s) ❑ Meter Surcharge ❑ Sanitation Capacity Charge ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Turn on Charge ❑ Uncollected Account - Name ❑ Inspection Fee - Tract - Fee - ❑ . Plan Check Fees Water 1 Sewer - Tract - ❑ Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit ❑ Other Remarks: �Cy �C�C.» ��l�.V� -PoPy to: Cash Check Money Order fit. t?•; ... .. _ .. . ,r tr.r .,. .... ... is I ......... ....i .. .. ....._ ec Tr,, G.A. Code Water Servi Cashl CVWD-438 (11189) COACHELLA VALLEY WATER DISTRICT CASH RECEIPT DETAIL Remarks: Wo norAgg G.A. Code TOTAL COPY to: CashWater Service Check Money Cashier, Order CVAL438 (11189) Received Fe6m':,: Address:` WE -/q s. Account No., Lot(s) Service Addresi" 0 Meter(s). 0 Service(s) 0 Backflow(s) 0 House Lateral(s) 0 Detector Check(s) 0 Meter Surcharge Sanitation Capacity Charge a s 0 W.S.B.F.C. 0 Temporary Construction Meter 0 Turn on Charge 0 Uncollected Account - Name C3 inspection Fee - Tract - L:. Fee - 0 Plan Check Fees Water I Sewer - Tract - 0 Bond Payment - A.D. --Bond Xssmt. 0 Customer Deposit 0 Other Remarks: Wo norAgg G.A. Code TOTAL COPY to: CashWater Service Check Money Cashier, Order CVAL438 (11189) EC SEWER SERVICE, INC. dba ECONO SEWER SERVICES P.O. BOX 192 • PALM DESERT, CA 92261 176n1 346-2793 17601 328-7760 JOB WORK ORDER, 14 8 S0 ` ' FAX (760) 347-4978 DER DATE OF ORDER SERVICE CODE PHONE TE7HhN HELPER STARTING DATE BILL TO C G TYPE OF WORK ❑CLEAN DRAINS OTHER ❑ SEPTIC TANK ❑ GREASE TRAP ❑ SEEPAGE PIT ADDRESS❑ CITY G(� JOB NAME AND LOCATION IL I ADDITIONAL WORK NEEDED: TANK SIZE: PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1'/2% PER MONTH CHARGE AFTER 30 DAYS. DESCRIPTION OF WORK: / CONDITION OF TANK BEFORE SERVICE Good _ Trash & Garbage _ Excessive soap _ Fair _ Overflowing _ Sand Poor _ Blockage _ Repairs Needed Very Poor _ Odor Roots _ More frequent service needed e homeTotal amount due El6tal 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 DA COM TEDORK WBERED BY �,�I TOTAL AMOUNT $ e homeTotal amount due El6tal billing to Signature for above work: or be mailed after I hereby acknowledge the satisfactory completion completion of the above described work. of work