0307-108 (PLBG)(0
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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
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
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 & Professidnals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to.c�ruct`fhe project (Sec. 7044, Business & Professionals
Codej.
() I am exempt underpSection/ B&P.C. for this reason
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' compensaa Tori laws of California, and agree that if I should become
subject to tho'rkers' compensation provisions of Section 3700 of the Labor
Code, I shalt fto't,hwith comply with those provisions.
Date. Applicant
Applicant
..''% �: Failu,✓''r
Warningre 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 forinsp ction purposes.
'Signature (Owner/Anent) .<'`_—/' Date
�i -BUILDING PERMIT - PERM'T# -�
0307-108
DATE VALUATION LOT TRACT
07/0/2M $1.000.00
JOB SITE�•��+�y�3�y
APN
�y
ADDRESS .'i i�"TS, 1Fi.7V-
OWNER
CONTRACTOR / DESIGNER / EN INEEk
L"DVlp, M GEORGE WISP,
OWN Ic,R}3L RDER
534685 E' SENHOWl• R DR.
LA Q9JNTA CA 92253
USE OF PERMIT
Y!LiI'h�.{NiAaG
'
NLWF-IZ HO()K.U'Pi'3 ? TYC ADANDOP8W.MZIJT•
VALUATIUM 1,00D.00 1.2
EISITll+lA7(. D COST OF COMMl7•=0144
�SGCi?�iISJ
PFR!! ff 1+"u siwzy
PixmmN0 trEI: -- 9m�,R 101-000-419-000
I
J'UI. I, 2003
CITY OF LA QUINTA
FINANCE DEPT.
i
SUB-`rO TAT., CON=UCII014 A14D PLAN CIECK
$30.00
LESg PRE-PAJD FE M
$0,00
IOTA L P.t RNIr"(' FE 5' DUE NOW
M.00
RECEIPT ��
DATE /
BY=
PRE FINALEDINSP
'�
f,/ i 4 `
i
INSPECTION RECORD i
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
i
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
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:
{
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COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
N06 96059
Received From: W:
Address: 4. -
Account No.
Lot(s) 9
Tract
Service Address
Dr,
G.A. Code
.0 Meter(s)
$
• Service(s)
• Backflow(p)
0 House Lateral (s)
• 'Detector Check(s)
• Meter Surcharge
2 -Sanitation Capacity Charge V
0,W.S.B.F.C.
• Temporary Construction Meter
• Turn on Charge
0 Uncollected Account - Nam
0 Inspection Fee - Tract -
Fee -
4
0 Plan Check Fees Water / Sewer -
Tract -
• Bond Payment - A.D. --Bond
Assmt.
• Customer Deposit
• Other
TOTAL
Remarks: h -1
C
O'Copy to:
Cash Water Service
Check t/ 41
Money Cashle
Order
CVWD-438 (eves)
drawing of record.
VALLEY WIDE PUMPING SERVICE
"Your Waste Is Our Problem"
1 nn C a,.,.;%AI. e,,;4-- 1100
.
JOB INVOICE
8615
1 V V J. JLII II IJ6 Vvay JUILG IJ,) -
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE ORDERED
PALM SPRINGS, CA 92262
Gallons i
L
ORDER TAKEN BY
ATE PROMISED ❑ A.M.
(760) 322-2400 (760) 347-3545
❑ P.M.
BILL T .��
P D/
n1
—e_ Y
AGDRES
ME NIC`
f/v
ELPER
AME D CATI N
❑ DAY WORK
DESCRIPTIONOF WORK
Locating / Opening Fee (per hour)
[3CONTRACT
❑ EXTRA
d.✓ �v..e_
b.v
Size System: /11 Ilk V
QUANT.
?
'
V
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons i
S
Pumping Fee per 1000 gal.
Dumping Fee pe 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Size System: /11 Ilk V
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR
WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
- LABOR
AMOUNT
TOTAL
MATERIALS
MECHANICS @
TOTAL
LABOR
"
HELPERS @
I hereby acknowledge the satisfactory
completion'of the above described work:
TOTAL LABOR
I
TAX
SIGNATURE
DATE COMPLETED
TOTAL
To Roorder Call NEBS CUSTOM"printing service TOLL FREE 1.8W-88&6327 NEBS, Inc., Peterborough, NH 03458. Ref. No: G 710703566
r
NOTICE TO OWNER
Under the California Mechanics Lien Law any contractor, subcontractor, laborer, supplier.
or other person who helps to lmproJe your property, but is -not paid for his/iter mor -k, or
suppiies, has a right to enforce a claim. against your property. This means that after a court
hearing, your property could be sold by a court officer and the proceeds of the sale used to
satisfy the indebtedness. This can happen even it you have paid -your contractor in full if the
subcontractors; laborers or suppliers remain unpaid,
To preserve:their right to file a claim or lien against your property, certain claimants such
as subcontractors or material suppliers are required to provide you with a document entitled
"Preliminary Notice:' Original (or prime) contractors and laborers for wages do not have to
provide this notice, A Preliminary Notice is not a lien against your property, its purpose is to
notify you of persons who may have a right to file a lien against your property if they are not
paid,. Generally,, the maximum time allowed for filing a claim or lien against your property Istl
ninety (90) Days after completion of your project..
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY;,
YOU
ROPERTY;-
YOU MAY WISH TO TAKE ONE OR MORE OF THE FOLLOWING STEPS.,
1) Require that payments be madeAlrectly to subcontractors and material.suppliers through
a joint control. Any joint control agreement should include the addendum approved by the
Registrar of Contractors.. 1
2) issue joint checks for payment, made out>to 1POW your contractor and subcontractors or
material suppliers involved In the project." This will help to insure that all persons due payment
are actually paid.
3) After UPON making payment on any completed phase of tqe project, and before making
any further payments, require your coritFactor to provide you with unconditional lien releases
signed by each material supplier, subcontractor and laborer involved in that portion of the
work for which payment was made. On projects Involving improvements to a single family
residence or a duplex owned by Individuals, tlie�persons signing these releases lose the right
to file a claim against your property. In other types of construction this protection may still be
Important, but may not be as complete. TO PROTECT YOURSELF UNDER THIS OPTION YOU
MUST BE: CERTAIN THAT ALL MATERIAL SUPPLIERS, SUBCONTRACTORS OR LABORERS
HAVE SIGNED. '