0108-095 (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
Profe;!�sionals Code, and my License is in full force and effect. ,
License # _,...' Lic. Class Exp. Date
746359 C4,2'tlkC
Dated ^ C'v�'� +� 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.
( ) • 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.
2 TAIfK74)ND J�rP9e�F•311
(This section need not be completed if the permit valuation is for $100.00 or less).
(.) I certify that in, the performance of the worm: 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 withs those proylslons.
Date
ai • ^a t Applicant
tir ! yPr r ..rib .
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—.f*
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 cf such I
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.
Or twf
Signature (Owner/Agent) �� Date"`/ �S
BUILDING PERMIT - PERMIT# ...�. ,�.'..,.�"
DATE /� VALUATION LOT Q},� TRACT
JOB SITE
ADDRESS fa
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
SAY -1 00 MA 01-1ANDE
: SA031 BAUX- RD DYD30Q CA 92201
:4':.A. QUA -A
alk 92261
(760;346pV93 Mx L :i42
USE OF PERMIT
;Sd�P�'1C •A���24XiirtRA:�',�°�°A'�FI�fk. d;CJ�{��f.;5'
VAUJA`9`ION Do IA9
` .T•it NIVID 0015T OF C6d'NSIR—XA14rfb'[
.G•gVJuF/'Ju'S9
PI. UAWING3 Fid: - SEWEIR 103-000-439-000
"yy
B -TOTtAL CCOMMSTr YM ION, ARD PI" C-11ECK
$10. 00
T9
$0,00
2001
L
CITY 0,' LA OU!Nbl
RECEIPT
DATE .. A
7
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
4 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 Wali Firewall
e
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 Pibg. 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
Gas Piping
Gas Test *
_
Q
v W
Encapsulation
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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F i ' nreK� l COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL'
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Tract
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Money
n Cashier '
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P
D D t '
# EC SEWER SERVICE, INC.' JOB MORE ORDER .
dba ECONO SEWER SERVICES
P.O. BOX 192 • PALM DESERT,- CA 92261 14840
17RA1 4dit_0702 17QA1 770_77RA
•
FAX (760) 3474978
TOTAL PUMP
DATE OF ORDER -
DISPOSAL FEE
SERVICE CODE
PHONE
TECHNICIAN
HELPER
STARTING DATE
TOTAL MATERIALS
y
QS
DATE COMPLETED-
WORK ORDERED BY
TOTAL AMOUNT
BILL TO
<" �
TYPE OF WORK
❑ CLEAN DRAINS
❑ OTHER
ADDRESS-
Q — 100 ��,
❑ SEPTIC TANK
❑ GREASE TRAP
CITY
❑ SEEPAGE PIT
JOB PtAME AND LOCATION
ADDITIONAL WORK NEEDED: -
TANK SIZE:
PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1'h% PER MONTH CHARGE AFTER 30 DAYS. +
'r DESCRIPTION OF WORK:
t ,CONDITION OF TANK BEFORE SERVICE
_ Good _ +» %>�� ."_ Trash & Garbage - . " Excessive soap
'Fair ." 't, y, "='Overflowing _Sand
Poor • , Blockage _Repairs Needed
_ Very Poor _ Odor
_ Roots _ More frequent service needed
Signature
❑ No one home ❑ Total amount due ❑ Total billing to
for above work: or be mailed after.
I hereby acknowledge the satisfactory completion completion
of the above described work. of work
s
TOTAL PUMP
DISPOSAL FEE
•TOTAL LABOR
'
PLEASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED.
TOTAL MATERIALS
y
DATE COMPLETED-
WORK ORDERED BY
TOTAL AMOUNT
$
<" �
Signature
❑ No one home ❑ Total amount due ❑ Total billing to
for above work: or be mailed after.
I hereby acknowledge the satisfactory completion completion
of the above described work. of work
s