9511-078 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
C) Cy � License is in full force and effect. �%� - ,A f �i291
ri W^ License # Lic. Classy I Exp. Date
1
Zn Date t ignatureofContractor( R
F OWNER -BUILDER DECLARATION
J W I hereby affirm that I am exempt from the Contractor's License Law for the
n_ following reason:
U) () I, as owner of the property;,or my employees with wages as their sole
Z 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. 7042r -Business & ProfessibnalS e).
() I am a em t under Section�(' &P.C. for thi �eason i
Date Signatureoftanrne^-
LON
O0 rn WORKER'S COMPENSATION Dte6RATION
Q I hereby affirm under penalty of perjury one of the following declarations:
C) d 2 Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
L O compensation, as provided for by Section 3700 of the Labor Code, for the
X LL LL, performance of the work for which this permit is issued.
p J J . ( ) I have and will maintain workers' compensation insurance, as required by
mQ U Section 3700 of the Labor Code, for the performance of the work for which this
O U permit is issued. My workers' compensation insurance carrier & policy no. are:
Il' rn Carrier Sit'�Z:L�..FiTr1,Z Policy No. 1,96`640
�t Z (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 1 should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Applicant
QWarning: 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, intarest 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 resuft.of.thi ppli
,acation agrees to, & shall, indemnify
& hold harmless the City o`f'(ndii ►-V1lAsF- 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 autho�represe fives of this to enter upon the
•
above-mentioned props for inspection urposes.
l� t"
Signature (C+wner/Ag Oats /'�/ I�
- w
A`°'
BUILDING PERMIT
PERMIT��_t
DATE A4 Y-1
VALUATION `d4UtS
LOT
TRACT /
JOB SITE ADDRESSAPN
54'i-2ti11 A IiDA OBREGO.N
774403-02;5
OWNER
CONTRACTOR
.i7EN.BORR ENTC,Ij EERTNG& CON,.
NAIUMIA.A HESSFE
68175 BERROS COIJRT
542.11.AVENIDA 0BRECiON
CKI IEDR AL MY CA 92234
L.A. QUINfA CA 92253
(619)327=2200 CBL## 35:17
DESIGNER/ENGINEER
USE OF PERmtILUM.13INU
SEWF.;Ii. CONN? f T
1
FEE DESCRIPTION
FEES
CON U A A&IOU-NT 2,724.00 LS
n1*141'IEI71ED C(Ygf PF CONSTRUCTION
2#724.00
PI.UNWING FEE -- SEWER 10ۥ-000-419-000 $.30.00.
SUBTOTAL CONST ZUMON' AND PLAN CHECK
$30,00
LESS PILE -PAID PEES
$0.00
OTAT, PER:IWIT FEENS DUE NOW
$30.00
11•
RECEIPT
DATE
BY
DATEANALED
INSPECTOR
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS I 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.
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Set Backs
Footings
Bond Beam
Final
BLOCKWALL APPROVALS
PLUMBING APPROVALS
Waste Lines
Water Piping
Plumbing Top Out
Shower Pans
Sewer Lateral
Sewer Connection
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
Steel
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K for Finish Plaster
Pool Cover
COMMENTS:
POOLS - SPAS
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
68•>75G3 A
Date Signature of Contractor
OWNER -BUILDER DECLARATION
2129/9/6
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 �aTA'rxi r,wii) Policy No. 1396r,tit? ;
(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. 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./1 C°NTR°`#
DATE VALUATION LOT .9.51.14075 TRACT 291'
JOB SITE APN
ADDRESS
54411 A;ViiNIDA CYRRECON ' 774203025
OWNER CONTRACTOR/DESIGNER/ENGINEER
l A QWKTTA, CA. 92253 CA TH13f)KA i,. CfTY* CA 92231
6.1f9 272200 MA3577
USE OF PERMIT
141;%3 fZ c� cel
0.00
SUB -TOTAL C>OhIMUC TION AND .€ LAN CHECK $0.00
LESS Pit.E•Mri K.BES $0,00
TUFAL PCRM IT FIEKS 014, NOW $901
RECEIPT DATE BY DATE FINALEDINSPECTOR
INSPECTION RECORD
ft
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings Ducts
Slab Grade ReturnAir
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 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
Appli noes
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
Uti
lity Notice (Perm)
ft
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms & Footings Ducts
Slab Grade ReturnAir
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 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
Appli noes
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
Uti
HAMMER PUMPING INC. JOB INVOICE
" • P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
(619)360-7448
QUANT.
(619) 321-7448
PRICE
CUSTOMER'S ORDER NO.
DATE ORDERED
/-31-(?(.
ORDER TAKEN BY
DATE PROMISED ❑ A.M.
❑ P.M.
BILL TO
(�
p6 G
PHONE
ADDRESS
MECHANIC
lam. V
CITY
•
H L`PER
JOB N/iME AN LOCATION f
S` 64.1/
t�hA
Q--Y-
WORK
'0
DESCRIPTION OF WO
CONTRACT
❑ EXTRA
Out of Area Fee
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
b® O
Gallons
p6 G
Pumping Fee per 1000 gal.
0
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
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 Qa
HELPERS Q
TOTAL
LABOR
I hereby acknowledge the satisfactory TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE
DATE COMPLETED
TOTAL
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.
TRI=STAR CONSTRUCTION
P.O. BOX 542
CATHEDRAL CITY, CA. 92235'` "Y
ph. (619) 321-0898
fax. (6119) 321-7798'
TO; CITY OF LA QUINTA
-• r - moi'
PER MY AGREEMENT WITH TRI -STAR CONSTRUCTION I WILL, RE -SEED OR
OTHERWISE COMPLETE MY YARD AFTER THE INSTALLATIONOFTHE SEWER.
� THANK YOU
,LZ
signature
p ease priiit name
a yi, ;.
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