0108-094 (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
tr 8/xr
Date 4k _21-621 Signature of Cpntract - ✓''
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.
JA,;4.• 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.
'STATR FUND 1=221.01
(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 prgvisions,,,of Section 3700 of the Labor
Code, I shall forthwith comply with those•provisions.
k
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.
n 'hisapplication.
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,fq,inspection purposes.
lel?�•✓
Signature �(Owner/Agent); J �v� l'�o ^�• Date el A
/ BUILDING PERMIT PERMIT#
DATE ; / VALUATION LOT 01W094 TRACT
JOB SITE APN
ADDRESS
00-=5 1119M ANDD
OWNER _ CONTRACTOR /DESIGNER / EN INEER '
ESSV,.R Y
LA QCWC
USE OF PERMIT
;l LX1 f(}
VAGI VA ! ,tON
P.035 117,. .M.RD, T2 DIO, CA 2x(f]
PALM :r EIMT C.A, 912261
l Q s�6aw7 3 MU 342
-4150,00 u
,t:STMKOD COST OF CONRIMM011 291504*
Citi 0. t.t� QU!i1lTA
flfriAliCE DEM
RECEIPT DAT /�, f f BY DATE FINALED INSPECTOR
UM 1014 AND PIAN CI3:WX
$30.00
LTMS PR:PATD'1,7
$O.AD
,..
AUG - 9 2001
jkliA r -mm M.Rs :01:E HOW*
Citi 0. t.t� QU!i1lTA
flfriAliCE DEM
RECEIPT DAT /�, f f BY DATE FINALED INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
- BUILDING APPROVALS
MECHANICAL APPROVALS
Set BaN s
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 I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
WahV Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Sh r Pans
O.K. for Finish Plaster
Sewrcr Lateral
Pool Cover
Sewer Connection �g �/� /
Gas Piping
Encapsulation
Gas Test ((
Appliances
Final
Final
Utility Notice (Gas) l 7
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Recept&:A� les
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
ECSEWER. SERVICE, INC. Jo o MORE ORDER
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT, CA 92261 f 14 8 3.J'
aza
1�n► d_as�
9�02 1�n► 29_77rn
` FAX (760) 347-4978 -
DATE OF ORDER
.
DISPOSAL FEE
SERVICE CODEPHONE
TECHHNIICCI�AN
HELPER
STARTING DATE
PLEASE PAY FROM THIS.INVOICE.NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
-
BILL T - -
TYPE OF WORK
TOTAL AMOUNT
❑ CLEAN DRAINS
❑ OTHER
ADDREs
Q_
❑ SEPTIC TANK
GREASE TRAP
CII Tr
❑ SEEPAGE PIT
JOB NAME AND LOCATION '
ADDITIONAL WORK NEEDED: - i
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
t
❑ No one home ❑ Total amount due ❑ Total, billing to
Signature for above work: or be mailed after
- I hereby acknowledge the satisfactory completion . ' completion
of the;above described work. of work
t .
"t,
TOTAL PU
.
DISPOSAL FEE
- -
TOTAL LABOR
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 ❑ Total, billing to
Signature for above work: or be mailed after
- I hereby acknowledge the satisfactory completion . ' completion
of the;above described work. of work
t .
"t,
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
085056
t6ral I—lei A"U
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'Received From z-7//
Date:--:.
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—0 Meter(s) j
$
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❑?Inspection Fee fct
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ter I Sewer - - L", 1 i
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5Other,,!N?;l.,— X.
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14 TOTAL $
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AN.
Zaahtl! a 4 t* .4-WaterServIce
Check ;iA�
M6
ney
Cashier 7
Order
CVWD-438 (11/89)