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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
r?rofbssionals Code, and my License is in full force and effect.
License # 07/31/2(
Liic.. Class Exp. Date
,.�'
".50999 Citi
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).
(7�.) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
O I am exempt under Section , B&PC. or this ason %l r _
Date Signature of Owner r. .AY 0t ,
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 STATE COMP CNS FU Policy No. 2241021
(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 withA.,se prod slo'As.
Date:
Applicant -J6 f'Syt � tS4
Warning: Failure to secure V rkers' Comp'�nsation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation,; damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions -"and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives,of this City to enter upon
/the -above-mentioned property for inspection pLirpos Isc^- , (�
Signature (Owner/Agent): , �v/i6f� �'R') * Date,./ !�
BUILDING
PERMIT#
E
PERMIT
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DATE VALUATION LOT
IOM9/ G
TRACT
JOB SITE
APrI
ADDRESS 51-275 C"i"E t31'ife9IXTAKLA
OWNER
CON'T�RAAC{T9ORRt/DESIGNER
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7$-4751.ACRESITADR
35-450 PF—GAM JS CT,
PA,LM DE"hw T CA 92211
THOUSAND PALMS CA 92276
(760)345-6166 G Lely'
21,97
USE OF PEEyRMII�TTypO,/
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SUMP CONNECT/SEPTIC AHANOONl?MEN
VA4VA.TT.ON
ZOO, DO LS
Ksrr '.4.T'K-j COST me G'C3Nt�T1r'i.i1C'nos
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PFe:F00T V719 S -OM 1f1AIZ'9t: .
PLUMBING FEE -- WWER 101 -WO -419-000 $30.00
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SUB -TOTAL COIRST ,K C. -:.a,01 'AND 11-1-Au47 CE`1Ciu.K
I M33 11"RE-PA FL. ES
$0,00
OCT 0'9 2003
CITY OF LA QUINTA
FINANCE DEPT.
RECEIPT
DATEt�
BY '' d "
DATE FIN ED
INS OR
INSPECTION RECORD
d 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
OX 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection p
Encapsulation
Gas Piping
Gas T
pliances
ZQ& Z10iFinal
COMMENTS:
*
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Final D 3
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbftures
—Main Sirvice
Sub Panels
Exterior[ Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
s
,Final
,Jtility Notice (Perm)
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL r49 98222
Received From:! l �1=1�'. '{ ('Y�` .!A,f3` E', ' . C�l hLLL STOM
Address: % S r'� Lec C i<fE� A /'!1 -Lm ,�L C 5 Z j'
Account No. (J; J ..�t _� is 3 109- Lot(s) Tract � E
�--
Service Address �" �.f �✓�-(� t�J'I1q�%{' G.A. Code
❑ Meter(s)
❑ Service(s)
❑. Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
'p' Sanitation Capacity Charge ? —1
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
0 -9 -
TOTAL
Remarks: ACV r'Yf�1l���E
�mCopy to:
Cash �;xF = Water Service
;.
Check
Money'" Cashier
Order CVWD-438 (11189)
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SANCO2502 Morongo Trail
PUMPING SERVICE 1
Palm Springs, CA 92264
(760) 327-8859
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S{OLD TO
SHIPPED TO
STREET _
STREET
DATE
CITY STATE ZIP
CITY STATE ZIP
CUSTOMER ORDER
SALESMAN ----[TERMS
F.O.B.
DATE
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PAYMENT DUE UPON,RECEIPT
A2avf 74 -xCvlc�l�7`i N
ro 03 —0b q 4Il�d�i2 91.0
+ CUSTOMER'S ORDER NO.
DEPT.
1
NAME:
ADDRESS:
CITY, STATE, ZIP 1,Cp1 ,,A.. Ctl. +
QUANTITY DESCRIPTION PRICE AMOUNT
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RECEIVED BY:
KEEP THIS COPY FOR YOUR RECORDS (� ,
@1998 R®IFORM9 SL320
j WES CLARKE PLUMBING, INC.
A PLUMBING FAMILY SINCE 1932
35-450 Pegasus Court, Palm Desert, CA 92260
LICENSE #650999
Phone: (760) 345-6166
Fax: (760) 772-0041
October 10, 2003
City of La Quinta Building Department
78495 Calle Tampico
La Qui.nta, CA 92253
Attn: Danny Crawford, Inspector
Re.- 51275 Calle Guatamala
Dear Mr. Crawford:
On October 10, 2003, Wes Clarke Plumbing, Inc. installed a connection for CVWD
sewer lateral and deleted a 750 gallon septic tank with a 24' deep x 5' wide seepage pit,
pumped and filled with washed plaster sand. I
Since ely,
Walker Holkesvig
Job Superintendent