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9612-087 (PLBG)9 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 [DATE Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date 684363 A 4 Date ! u� r 4 !Signature of Contract OWNER -BUILDER 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. J( ) 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. STS.".i"ri'IFIMNID 11396640-% (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: r' 1 �i< .l /t f APPlicanfr m�._, 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. Signature (Owner/Agent)(!/ 7 //IDate — Nr . 1 , e, i BUILDING PERMIT VALUATION $1 -iq 0t) LOT ADDRESs ,,4�-095,AVeaMJDA VlaREttOiN OWNER on .117 US H & t,f VICIA ftf- A. NIDA 06REGON LA (11 JIK A CA, 9225:3 USE OF PERMIT PLUMAJINC11 S1~ ITIC A811NDON4 Sr"WER C0NNSCT' COf+i°l'RMT AsMOUKL' PERMIT# CONTROL# 9612-687 TRACT 4480 APN 774-20-617 CONTRACTOR / DESIGNER / ENGINEER D1vPJSOEN ENGINIEEIZING'4ft COMM'. 6811,15 BEPIROS MUM' C TF-JfsT3RM. CfTY C11 9221,1 (mgpv-2200 - CK4 3577 IM5,00 1.8 PLtIN181►NO NAtr-- SEWHR lt)l-i3tT{}-419-t)t)f) S30.00 SL!! y'1'C�'1 �1.d, coN, ; mlJCq 100 t1N 1) P1,AN C1tF-0Z SM 00 LT:SS PRT -PA)D 7S $0.00 "t'UrAT, PIIERN iT FEES 01111 +,1ViJ"10V I S301114) RECEIPT I DATE I BY/ I DATE FINALED I 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 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 Encapsulation Gas Piping Gas Test A planes % Final COMMENTS: 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) HAMMER PUMPING INC. JOB INVOICE P.O. _ Box 2448 CATHEDRAL CITY, CALIFORNfA 92235-2'448 r IR1C1 QRn_7AAQ Iva.iI vvv . - -- (619) 321-7448 CUSTOMER'S ORDER NO. DATE ORDERED f—A— 97 ORDER TAKEN BY DATE PROMISED ❑ A.M. ❑ P.M. BILL TO PHONE ADDRESS MEC _ N�CC4 CITY HELPER JOB NAME AND LOCATION6-11--© (`� Y O Jam+ "'�' e � CYDAV'WORK DESCRIPTION OF WORK � - LJ 1-*.- �VJ �� 1 ❑ CONTRACT, ❑ EXTRA r — QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT p Q Gallons OBC) Pumping Fee per 1000 gal. % X IFS— '0 ©() Dumping Fee per 1000 gal. <° no Out of Area Fee - . Locating / Opening Fee (per hour) Size System: 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 Q HELPERS Q TOTAL LABOR I hereby acknowledge the satisfactory completion of the above described work: TOTAL LABOR TAX SIGNZTRE,,,,,, Tirl COMPLETED 2 7 TOTAL 3 S C NOTICE TO OWNER Under.the California Mechanics Lien Law any contractor, subcontractor, laborer, supplier or other person who helps to improve your property, but is not paid for his/her work or supplies, 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 if 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 is ninety (90) Days after completion of your project. TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY, YOU MAY WISH TO TAKE ONE OR MORE OF THE FOLLOWING STEPS: 1) Require that payments be made directly to subcontractors and material suppliers through a joint control. Any joint control agreement should include the addendum approved by the Registrar of Contractors. 2) Issue joint checks for payment, made out to both 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 the project, and before making any further payments, require your contractor 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, the 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.