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9903-064 (PLBG)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 746159 Cat 2129;00 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. ( )r 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. Date': = - ! 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. • V ture (Owner/Agent) ! Date BUILDING PERMIT PERMIT# '/rHF i tt. t DATE VALUATION 31-W.00 LOT TRACT • 1'�'•C161 JOB SITEv ` APN p ADDRESS 51.41.10 EISEdN��� VER DR 773-092-003 OWNER CONTRACTOR / DESIGNER / ENGINEER MARCHH+ ROz 1;CONO SIrWLIt 54-RVICL 51.400 EfSENHO't EiR DR 84035 CAf3AWN R.O. INDIO, CA 92271 LA QUINTA CA 92253 PALM DLESU.'Wr CA 92261 (760)W-27113 0111,# 342 USE OF PERMIT PLUMBiNO3 SEP -f[C ABAMX1N, SEWER CON- f A—,r (L&M D PROJECT ll9b-20) V CONMACT, AMOLMT 1.500.00 LS E.IffiiIIt4lED(.W Of [.Nl\NTf-''iJ%..1l©ti 1riVti.�ili PERMIT FEE SUINIMAR F'lAINVINO 6`F•E -- INEWER 1.01-000.416-000 S I I11f `f r13�lvYfAi., C'! I iS'!'!?t rt. i7UN AW) KAN (741F(T tv) 00 LESS PRE-VAID FMS. $0.00 Tr'';tAL PERMIT FEWS 01Uk, NOW �3f1a1N1 RECEIPT DATE BY i DATE FINALED INSPECTOR 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 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 Neater Final Water Piping Plumbing Final Plumbing Top Out Equipment EncCosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection— c ' Encapsulation Gas Piping Gas Test Appliances Final 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) COMMENTS: ECONO SEWER SERVICES P.O. BOX 192 PALM DESERT, CA 92261 r7r,n1 *AAA -7702 r7rn) Z7Q-77rn J0 D WORK ORDER 1075 FAX (760) 347-4978v - - v DATE OF ORDER 99 CUSTOMER'S ORDER NO. PHONE MECHA HELPER STARTING DATE BILL TO � ORDER TAKEN BY ADDRESS DATE COMPLET O / I WORK O ED BY O ❑ DAY WORK / P ❑ CONTRACT CITY Total amount due ❑ Total billing to ❑ EXTRA JOB NAME AND LOCATION JOB PHONE DESCRIPTION OF WORK PAYMENT TERMS NET 10 DAYS FRIUM 1'/t% PER MONTH CHARGE AFTER 30 DAYS. Signature j� - "-rbr above work: or I hereby acknowledge the satisfactory completion of the above described work. be mailed after completion of work TOTAL MATERIALS TOTAL LABOR PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TAX DATE COMPLET O / I WORK O ED BY O TOTAL AMOUNT 5 ❑ No one home ,0 Total amount due ❑ Total billing to Signature j� - "-rbr above work: or I hereby acknowledge the satisfactory completion of the above described work. be mailed after completion of work E. C. Sewer Service, Inc. dba Econo Sewer Service PO Box 192 Palm Desert, CA 92261 (760) 346-2793 or 328-7760 Fax (760) 347-4978 License C-42 #746159 Date: (� RE: City of La Quinta Project #98-20 Sewer Connection the owner of property at rj o a �; 5�-_ N L 4e �J ( Print Name) (Print Address) in the City of La Quinta, release Econo Sewer Service of responsibility for restoring my property to to it's original state prior to the sewer connection. Please note the following areas they are released from: l . A, e4,/i,✓ 2. 3. 4. tatrue of Econo Sewer S rvice Employee Signat gnure o Property r