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0012-213 (PLBG)U) in N W o�C) ' LLJ O O ww ►- a Z C0 LO N ON U °) d Q Z ,a0 LL X w — mUU O d rn H It _Z Ob 5 �O Q J 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 6r5r, A H Vl4tte Signature of Contractor OWNER -BUILDER DECLARAT,„t;ON 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 p�rfo�rmance of the work for which this permit is issued. (fir) 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. STATE FUND 044-00-00192U (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 4hose,provisions.' Vate: / / ' /l _-"Applicant z\...> 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..11 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 purpo�s�/eS Signature (Owner/Ager�ft)ti l 1 –���' Date BUILDING PERMIT PERMIT �V# i DATE VALUATION LOT 0012-213 TRACT S1AWAO JOB SITE ADDRESS 57,HM. AVZNMA CAi2.12Air ZA APN 773415-027 OWNER CONTRACTOR / DESIGNER / ENGINEER MR. AND boflW.1! GURL WIYW, DENBOM INOINEMU90 & CONST. 5.2.105 AVIWU)A CAMRA MA 68.173 Bh .U3 COURT LA Q{. O A CA Q2253 CAXHW X, CITY CA 92234 (760)327-2200 MIX 3577 USE OF PERMIT 101%It Xj SKPTIC ANA14L10N. ;B Y2, CGN1Jtr T. 14'%V -MOD PROJEM 2tJtJif V, VAWATION 11500.00 L3 l�.�r"�I!iA'1ED COST OF CON.IVIVYYi':TiONa ,NUi?.Gp P>s IRM T FEE MMMARY PIAIMBRIG FBA -. SWRR 101.000-A 19.000 sm,00 BUD-7ti7'I'AL C0NIMT?Cl ON AND PIAN C ECK. V30.00 IMS PPX-PAMPM 1 $0.00 IVJ'Ab P RMIT VMSDUE NOW 1 "0100 RECEIPT I DATE — ' r� {t.. L I BY f 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 0. 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 BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. 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 . O 57 Encapsulation Gas Piping Gas Test 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: HAMMER PUMPING INC. JOB INVOICE, P.O. Box 2448 CATHEDRAL CITY, CALIFORNIA 92235-2448 17ani 1an-7AAR r . . (760) 321- 7448 DESCRIPTION OF MATERIAL USED CUSTOMER'S ORDER NO. DATE ORDERED r, (,) Gid,; Gallons _ / _ C� ORDER TAKEN BY DATE PROMISED f i A.M. Pumping Fee per 1000 gal. P.M. BILL TO PHONE ADDRESS (60o MEN C� CITY HELPER NAME AND LOCA ON (/''', G - �eYDAY WORK ( S Out of Area Fee SCRIPTION ORK ❑ CONTRACT ❑ EXTRA Locating / Opening Fee (per hour) J C —C QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT (,) Gid,; Gallons © of,) Pumping Fee per 1000 gal. (60o Dumping Fee per 1000 gal. Out of Area Fee Locating / Opening Fee (per hour) 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 @ HELPERS @ TOTAL LABOR I hereby acknowledge the satisfactory TOTAL LABOR completion of the above described work: TAX SIGNATURE DATE COMPLETED j O F TOTAL YS c o