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0107-132 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby,affirm under penalty of perjury that I am licensed under provisions of Ci.apter 9�commencing with Section 7000) of Division 3 of the Business and ProfesQmals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 74,6159 C47, ME, 2/28/02 Date -7-- I Signature of Contractor, OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am txempt 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: Carer Policy No. STA UP FUWD !!57721'1-01 (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 withl'thbse provisions. Date:--! - ! ✓ 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 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) �' p Date.';' BUILDING PERMIT PERMIT# DATE VALUATION LOT c��c,'i 4;2 TRACT JOB SITE APN ADDRESS OWNER CONTRACTOR/DESIGNER/EN INEER 7r'87:t?RIY.,VM 84W 0,t,%WK RD, U"O, CA. 92201 ?.AQtfMA PALMDESW CA 92261 C1603346•217S:s MTA 342 USE OF PERMIT SMIC a, 1Re:LAflJOfdYi+tfaNT; fiEW= rtO0rX-UP VALUATION X650,00 W4 .N.S.A.hAC,LRASl.0.'r.W '!..`✓YT 03F hviJ,tTMW \.�,i ON 2109.00 M�,177��r�gg".d{.�', Ys`//:1 1011. t � L�gylp'�3:7fii'Y, 4 � y pryt 9 p ! /�q��y a l.+li'1l:PY.1''iW' h'.LE "oh- PIR 101-000`�T k9-00�.! r•'�JY.�t+ C11'I �f L+'� QU�ylri KM_ -TOTS, fRJMMITC[' ON AND 'LAR CHECK. $30.O0 1 LM F99 -FAM MZ $01M TMAL ?°1RM' 1:='0'15 VOTE NO'ut+' SX1100 RECEIPT DATE ! n) BY r DATE FINALED INSPECTOR INSPECTION RECORD 6PERATION 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 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 -t Gas Piping-��"'-�' Encapsulation Gas Test Appliances Final Final 01 � Utility Notice (Gas) Utility 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: COACHELIA VALLEY WATER DISTRICT CASH RECEIPT DETAIL --- - ---._ .:_ . - - -�--- --- N9 ,0$5059 aceivedFrom: !� Address: u /' Account No. Lots) -/ S Service Address ❑ Meter(s) ` ❑ Service(s) ❑ �Backflow(s) L" C�FtouseLateral(s) ❑ DetectorCheck(s) ❑ Meter Surcharge ° SS' t[ anitation Capacity Charge ❑ W.S.B.F.C. { ❑ Temporary Construction Meter ❑ Turn on Charge gF, ❑ Uncollected Account - Name &F' ❑ Inspection Fee - Tract - Fee - F' ❑ Plan Check Fees Water/ Sewer - Tract - ❑ Bond Payment - A.D. - Bond- Assmt. ❑ Customer Deposit ` ❑ Other Remarks: rte' * � ( opy'to: J Cash J Check , Money Order Plans picked up i. S.M.I. Flood plain plan Grading Grading plan Developer Impact Fee Called Contact Person Subcontactor List A.I.P.P. Date of permit issue Grant Deed H.O.A. Approval IN HOUSE: - Planning Approval Pub. Wks. Appr School Fees G.A. Code ra L tt TOTAL $ilo ' 00 Water Service u Plans resubmitted l-onstrucnon Mechanical 2"' Review. ready for corrections/issue Electrical Called Contact Person Plumbing Plans picked up S.M.I. Plans resubmitted Grading Review. ready for corrections/issue Developer Impact Fee Called Contact Person A.I.P.P. Date of permit issue Total Permit Fees Cashl CVWD-438111189) U EC SEWER SERVICE, INC. dba ECONO SEWER SERVICES P.O. BOX 192 • PALM DESERT, CA 92261 (760) 346-2793 (760) 328-7760 FAX (760) 347-4978 E NAME AND LOCATION ADDITIONAL WORK NEEDED: JOB NONE ORDER 14901 TANK SIZE: STARTING DA1 ❑ CLEAN DRAINS ❑ OTHER ❑ SEPTIC TANK ❑ GREASE TRAP ❑ SEEPAGE PIT 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 ❑ No one home ❑ Total amount due. Signature for above work: or I hereby acknowledge the satisfactory completion of the above described work. 171 *eft'—',g —t - be be mailed after completion of work TOTAL PUMP DISPOSAL FEE ' TOTAL LABOR A PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TOTAL MATERIALS DATE COMPLETED WORK ORDERED BY TOTAL AMOUNT ❑ No one home ❑ Total amount due. Signature for above work: or I hereby acknowledge the satisfactory completion of the above described work. 171 *eft'—',g —t - be be mailed after completion of work