0012-222 (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.
Licenf(e # Lic. Class,--- Exp. Date•
Zf
A13j
tai AFk:M ` P l
Date I t� ! Signature of Contractor
OWNER -BUILDER DECLARA`T,jON.
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..
N( 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 t+��•D�rTP19:tZd
(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"ifs I should --,become
subject to the workers' compensatjon provisions of ection 3700 of the7-alior
CCdde, I shall forthwith comply with t 'ose.provisi n?.
,
�auate: f"` jN' � 11J� pPlicant t t" tei
Warning: Failure to secure Workers' Corr pensatlon 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
corrects 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 pro ett for inspection purposes.
'Signature (Owner/Agent)` / �'� •• r Date 1 °" I` , X
BUILDING PERMIT PERMIT#
4'
DATE VALUATION LOT �' ; ; -VCT
L . .
__.
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
MR At41 M . alARLF49 8MMO
DEMORR LrMINLUMING & C014gr
68_1175 D�E OU COURT
LA 0:111Wr'A CA 92253
C.N.VR£tDia.&LCWV = CIA 92234
(760)327-2240 cWh 3577
USE OF PERMIT
SP, IC AB.hi'IQdNaN . SEWER L'b7N1+iKN'. LOW -MOD PROJECT 2ow-21.
VALUATION 11000.00 LEI
Esm'". 2V COST Gy -CONSIrRUCTION
11900.00
PW M D IN 0 KE .99 MER 101-000419-000 $34.00
13.140raL ".."Myr MIM M119 NOW
RECEIPT
DATE,
BY-,,, I,
DATE FIN ALED
INSPECTOR
A
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 I
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 Ldcation
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 . a S, r
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final .2 .p! 5
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, CALIFORNIA 92235-2448
17an1 Zan-7AAR
QUANT.
�i vv� vvv . zz44v
(760) 321- 78
PRICE
AMOUNT
CUSTOMER'S ORDER NO.
DATE ORDERED
!0 p- p 1
—00-C71
ORDER TAKEN BY
TE PROMISED 0 A.M.
0 P.M.
BILL TO
Dumping Fee per 1000 gal.
PHONE
ADDRESS
MECHANIC
Out of Area Fee
CITY /
Locating / Opening Fee (per hour) i
HELPER
JOB NAME AND
CATIO -... �j
/
�`
9y r
❑ DAY WORK
DESCRIPTION OF WOR
GJ
erjh / / _
O CONTRACT
❑EXTRA
_\
aN
A SERVICE -CHARGE OF $20 WILL'BE DUE
ON ALL RETURNED CHECKS.
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal. x
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour) i
Size -System: f
r r
_\
aN
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
completion of the above described work:
TOTAL LABOR
TAX
SI ATURE
ST
DATE COMPLETED
2 G f
TOTAL
D