12-0220 (PLBG)LICENSED CONTRACTOR DECLARATION
U) . )hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
cel w ` Professionals Code, and my License is in full force and effect.
O License # Lic. Class/ Exp `'
Date
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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.
3.` 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:
Cartier Policy No.
STATE FUND 044-00-0019224
(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
worker compensation laws of California, and agree -that if 1 should pecome
subjecT to the workers' compensation provisions oofi ection 3700 of.the Labor
Cod, I shall forthwith comply with«those, pr'ovisio�!s`r�
D-afte. /Z- �, }; / ` u Applicant v-- .. X 0' V_ \,_6•:". •
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 re `acing to the building
conruction, and hereby authorize representatives of this City to enter upon
thgabove-mentioned property for inspection purpose
Signature (Owner/Agentj
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
•
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Retum 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
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=
Pool Cover
Encapsulation -
Sewer Connection
Gas Piping
Gas Test
,
Appliances
Final
COMMENTS:
•
-
t
7-23-0f
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_ .
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
i Tan► plan _ �aaA
JOB INVOICE
•
,. ......, �..... ....
(760) 321-7448
CUSTOMER'S ORDER NO.
DATE ORDERED
/ — r 6 - o r
ORDER TAKEN BY
DATE PROMISED 0 A.M.
0 P.M.
BILL TO
PHONE
ADDRESS
MEGh.I 1
CITY
HELPER
Jc : NAME LOCATION(Y q V r r Ni(v.,...(10 �+ ez
crb-A-y WORK
0 CONTRACT
0 EXTRA
•ESCRIPTION OF WO: S `/� `/ '/
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QUANT.
DESCRIPTION Of MATERIAL USED
PRICE
AMOUNT
CO 0
Gallons
O c 0
Pumping Fee per 1000 gal.
K,
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Dumping Fee per 1000 gal. x
.3-0(---9.
( OCA
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Out of Area Fee
Locating / Opening Fee (per hour)
o c ( /3 : ('(,
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR
AMOUNT _
TOTAL
MATERIALS
MECHANICS Q
TOTAL
LABOR
HELPERS @
n
I hereby acknowledge the satisfactory TOTAL LABOR
,_completion of the above described work',.
TAX
13NATURE
T / •. ��V ."l ;6 e• 7,. /
DATE COMPLETED
/ / (6 /0 (
TOTAL
. 9 0
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