0012-217 (PLBG)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 Z
1
sa AB F. LAS �y��12�i
l ate �'1 �ySignature 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.
[) I have and will maintain workers' compensation insurance, as required by
Sec ion 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 MIND
(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 shallnot employ any person in any manner so as to become subject to the
wor eis' compensation laws of Califwiii`a�, and agree that if 'I� should become
s u-ject to the workers"compensation provisions of Section 370 of the Labor
Code, I shall fo, hwith comply wit�jlhose.provislopsi �`�
t:�G>C� Applicant, SC ✓"`� -1
Warning: Failure to secure Workers' Com nsation coverage is unlawful and
shall subject an employer to criminal pend Ities 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 relpting to the building
construction, and herebuthorize representatives of4is City to enter upon
the above-mentioned pfop�erty fo1inspe6ion purpo 6.*"
ignature (Ownerh n� ���"(_ `"�"t Date``'
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 52,451 A .Vit:NMA CARR N74k
M_a1's- w
OWNER
CONTRACTOR / DESIGNER / ENGINEER
.1.M MMS, JOSE, L UM GARC IA
DERROERMWEERING & CONST.
52.151.A.MWED.A,CARRANZA
6-8-17VD I051C.t7CiR
LA. Qrb]rwm CA 92253
C,�1��1,7[[y't 7RAI,.�C�y rrY 'CA 92234
y t e
USE OF PERMIT
SEPTIC AB.AtJD014.19MR-k C0104EC.T. I.d3''lt3'•biOD PROMT2060-21.
2060.2.1.
VALCIATIOI+i 1,800,D0 Lo
ERSTMA CCa�,"i tib CC�P'ES"1`�,1�C"�"6C�!`d
FF.RLT i° YEE 9UMAIARY
PLUMBING "T, -- MWEIR 101-000-419.000 93e,01)
YKffi_1•0.6A{.u:'.\/.iWMi.R1./;•..,ft10•G-i .Wdic{"LAN 6.rHii'lw%.
y'130M
Ld'Gm PRU-PAM 17M
$0.00
TOT AL Yfi2IMTY1iXE8 DWN OW
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
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 x.23 , O / S 7
Gas Piping
Encapsulation
Gas Test
Appliances
Final
Final - p
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
17anm qan - 7AAR
1. ��� ��v
PRICE
CUSTOMER'S ORDER NO.
DATE RDERED
(760) 32k-7448
/J.O
ORDER TAKEN BY
DAT PROMISED C] A.M.
•�
D P.M.
BILL TO
f �`
PHONE
ADDRESS
Out of Area Fee
MECHANIt
CITY (
HELPER
Locating / Opening Fee (per hour)
JOB NAME AND LOCATI /
{/c /4+- /�
C DAY WORK
�t
\
DESCRIPTION OF WORK
CONTRACT
[J EXTRA
� t
l
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
QUANT. - DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
r Pumping Fee per 1000 gal.
•�
Dumping Fee per 1000 gal. y
f �`
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 Q
HELPERS Q
TOTAL
LABOR
I hereby ackno ge the satisfactory TOT41- LABOR
completion above described work:
TAX
SIGNATURE _
DATE COMPLETED
TOTAL
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