15350 (PLBG)4
P.O. BOX 1504
Building 78-495 CALLE TAMPICO
Address 53-675 dive Carranza LA QUINTA, CALIFORNIA 92253
_...._. J. Doulas Lynn
Mailing
Address p•C, Box 2942
City Zip Tel.
• Palm Desert 92251
Contractor
Tri. Star
P.O. Box 542
City Zip Tel.:
Catherd.ral City 92235 321-0898
State Lic. City
& Classif. 475515 Lic. # 672
Arch., Engr.,
I Designer
I Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, after, Improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to rile a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than rive hundred dollars ($500).
❑ 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build orrnprove for the purpose of sale.)
owner of the property, am exclusively contracting with licensed contractors to con-
s4ti�uct the project. (Sec. 7044, Business and -Professions Code: The Contractor's License Law
does not apply to an. owner of property who builds or Improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
s' l 1- }}
Date t f 1 `• Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No K" Company
k2e opy is filed with the city, ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate or Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND
SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE
HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION,
DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above..
mentioned, property for inspection purposes.
Signature of applicant -Date-
Mailing
ateMailing Address
City, State, Zip
No. 15350
LDING: TYPE CONST. OCC. GRP.
P. Number
Description
t Description Sewer Nook -up
Sq. Ft. No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
;timated Valuation
PERMIT AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const. A 30_CID
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL $30.00
REMARKS
ZONE: BY:
Minimum Setback Distances:
Front Setback from
Rear Setback from
Side Street Setba�c/lF
Side Setback frog
FINAL DATE
Issued
Validated
ne
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBIW FEES
1ST FL. SO. FT. @ $
UNITS
SLAB GRADE
2ND Ft. S0. FT. @
BONDING
YARD SPKLR SYSTEM
POR. SO. FT. @
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. @
POWER OUTLET
ROOF DRAINS
FOUND. REINF.
GAS (ROUGH)
DRAINAGE PIPING
CAR P. I SO. FT. @
OTHER APPJEOUIP.
REINF. STEEL
WALL S0. FT. @
TEMP. POLE
DRINKING FOUNTAIN
SO. FT. @
GROUT
URINAL
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER SYSTEM
FLOOR DRAIN
MECHANICAL FEES
_$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DtSH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
REMARKS:
LAUNDRY TRAY
AIR HANDLING UNIT CFM
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. @ c
BATH TUB
SO. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 11A c
SEWAGE DISPOSAL
SO.FT.GAR @ 3/4c
HOUSE SEWER
MESH
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE . PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEW R ;
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
�
i1
fV FINAL INSP.
FRAMING
FINAL INSP.
�F l
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIONATURESIINITIALS
.
GARDEN WALL FINAL
HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
� n
%U171 JVV-/YY0
(619) 321-7448
CUSTOMER'S ORDER NO.
DAT OR
—76 -�s`'
ORDER TAKEN BY
DATE PROMISED ❑ A.M.
❑ P.M.
BILL TO - ^\\
PHONE
ADDRESS
ME NIC
(Y
CITY
HELPER
JOB'IQI AlY (CA�LQN r I
JJ\ ✓C _ � i�
QDAY WORK
DESCRIPTION OF RK 1
❑ CONTRACT �
EXTRA
O
00
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
I
000
Gallons
TOO
Pumping Fee per 1000 gal.
s
00
Dumping Fee per 1000 gal. I
0�—
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
( Cf r /
A SERVICE CHARGE OF $20 WILL BE DU
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 Q
HELPERS Q
TOTAL
LABOR
I hereby acknowledge the satisfactory
completion a above descri ed work:
TOTAL LABOR
TAX
SIGNATURE J
DATE COMPLETE?
�d '(
TOTAL
r
I
=—
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 06t 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 fuli 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 the)_dre 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 suppliers3hrough
a joint control. Any joint control agreement should include the addendum approvbd 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 payrneiit
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`impiovements 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.
! •' COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Recelved From: 7 �-^ y�N�J. �OC.�EC. •n �,
Address: S 7 — �'� S f: V C' A %7 07
Account No. 60CY t o24,0% ,.0, 7 Lot(s) :7 Bc k
Service Address '5L: i—C--75 A V-2 C A R RAS -7—A
❑ Meter(s)
❑ Service(s)
❑ Backtlow(s)
❑ HouseLateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
nitatlon Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Tum on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ Bond Payment - A.D. --Bond
Assmt.
❑ Customer Deposit
❑ Other
Remarks:
❑Copy to:
Water Service
Cashier, r
V W D-438 (11189)
Cash
CheCk
Money
Order
BE 53^.8t
Tract SA .CTIA L. ITA
G.A. Code
S
TOTAL $
^'
Water Service
Cashier, r
V W D-438 (11189)