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0309-286 (PLBG)LICENSED CONTRACTOR DECLARATION � ' ".thereby affirm under penalty of perjury that I am licensed under provisions.of' . I— r Chapter 9 (commencing with Section 7000) of Division 3 of the Business and cit WFProfessionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 589.994 C-36 03M /2C (,,Bate 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. iI ( ) 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 STAVE bUND Policy No. , 25742,.300:4 (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: 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 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. Signature (Owner/Agent) Date - BUILDING PERMIT PERMIT# � 03W -2W) DATE VALUATION , ,LOT.TRACT 0%24/20C 2, il.Std3 JOB SITE ADDRESS Ba -145 ^6 (SC.'R'A. GRA;V.IZIf: APN OWNER CONTRACTOR/DESIGNER/EN (NEER 113A.111"TONO SCI CrIT COW JANY 0a43 VAS'%1� � RO,.BOX2146 LA. QUINTA CA .92253 INDIO a CA 92210 2571 USE OF PERMIT SFW, e x CMNIXTION, �EUIcABA114001111Mw14T y VALU'ATIUN 2000,00 L9 ROMLV A A ) COIRL Jai 2� R4 CIFIO 2pWWDD PFRW111 ]YTIM S'ETWU :Y MMM00 FEE - i3U7b'.R 41 -01 -OW -4,19-000 �3�J•�:t .. J Q D . 2 5 2003. .SEP C%_Ty O'FCEp jA 1 pINANCE sua-Tt'fSk, CnW11iU'C'C 01dr AM PLAIT CHECK �319•i�V RECEIPT DATE BY ( 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 POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric r 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 O.K for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances: _.- Final COMMENTS: Final Utility Notice (Gas) y 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) A Bin # City of La Quinta Building a Safety Division P.O. Box 1504, 78-495 Calle Tampico La Quinta, CA 92253 - (760) 777-7012 Building Permit Application and Tracking Sheet Permit # M101 -z86 Project Address: 8b — NS f� O+vner's Name: j/ r� , A. P. Number: Address: Q I / 7 v Legal Description: — Contractor: �Zc7®2 City. ST, Zip: S FTelephone: %6 D � 3 �— ( p . �� 6 �T<�.�f;'•'`� Address: f�_ l Project Description:��°� City, ST, Zip:i d ZZ6ZIV SiS�.J �� ✓�/ts0.+/: Telephone:7-6o-30 - 36 State Lic. #: S Gj' City Lic. #: 106o X. Arch., Engr., Designer: Address: City, ST, Zip: Telephone: - State Lic. #: Name of Contact Person: �Z,Ef-�, Construction Type: Occupancy: Project type (circle one): Ne+vAdd'n Repair Demo Sq. Ft.: # Stories: i Telephone # of Contact Person: 'D 3----�3�7 stimated Value of Proi <Z'000 APPLICANT: O NOT WRITE BELOW THIS LINE # Submittal Req'd Recd CKING PERMIT FEES Plan Sets Plan Check submitted Item Amount Structural Calcs. Reviewed, ready for corrections Plan Check Deposit Truss Calcs. Called Contact Person Plan Check Balance Energy Calcs. Plans picked up Construction Flood plain plan Plans resubmitted Mechanical Grading plan Y' Review, ready for corrections/issue Electrical Subcontactor List Called Contact Person Plumbing Grant Deed Plans picked up S.I.I. H.O.A. Approval Plans resubmitted Grading IN HOUSE:- ''' Review, readv for corrections/issue Developer Impact Fee Planning Approval Called Contact Person A.I.P.P. Pub. Wks. Appr Date of permit issue School Fees Tot2J Permit Fees (113' 75 COACHELLA VALLEY CASH RECEII DISTRICT L T N? 97468 v + `� v Received From- Date: / / - Address: l C/' Account No' Lot(s) Tract Service Address G.A. Code ; ❑ Meter(s) $ ❑ Service(s) ' 1 ❑ Backflow(s) > O House Lateral(s) -" " 0 DetectorCheck(s) ❑ Meter Surcharge 0-SanitationCapacity Charge ❑ W.S.B.F.C. ❑ Temporary Construction Meter ❑ Turn on Charge 0 Uncollected Account - Name - ❑ Inspection Fee - Tract - — - - Feer ❑ Plan Check Fees Water I Sewer - Tract - ❑; Bond Payment - A.D. - Bond Assmt. ❑ Customer Deposit ; ❑ Other ., 'TOTAL $ i + Remarks: (+W Ivilk ptopy to: Cash 4 t. Water Service r Check Money Cashier" Order CVWD-438 (11189) s t t Sewer Conneetior4Disdaimer The Coachella Valley Water District recommends homeowners hire a. Plumber or contractor to physically locate.the house lateral location before Abandoning their'septic system in anticipation of connecting to CVWD's main sewer lines: The'location of the,house lateral is vital for once the septic system is abandoned, the house will be unable to use running water until the sewer lateral is connected,to the sewer main lines. CVWD will make drawings of record for these'house laterals available to homeowners and while every effort is made to insure the accuracy.of these" drawings, it must be recognized that there may be deviations in these records due to. street improvements,missing house. laterals_or relocation of house _ laterals.' However, the district does acquire sewer lines and laterals from other agencies or subdividers which also may contain inaccuracies from the drawing of record: These deviations from the drawings of record are beyond the control of� CVWD; therefore, .the district will not be responsible for any charges incurred by the homeowner as a result of these inaccuracies. o July 1; 2002 ,w