9805-075 (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
. 4221.55. C36 C42, €1,``30!00
►!Date ` #Signature of Contractor •f•"
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.
AI 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.
(This section nee n 1744
o 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 those provisions.
vDate:. -f�/ `/ Applicant—
Warning:
pplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT .Application is hereby made to the Directd' of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under°or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above Information is
correct. I agree to comply with all City, and State laws relating to the b°u,�ld n g• �.
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
"Signature (Owner/Agent)'V Date`
BUILDINGPERMIT PERMIT# CONTROL#
LrJ 1L
���eee
DATE VALUATION LOT 9801-A.-07.15TRACT 7-105
,1 0 5
�1 .Ibd� �' '3.%lAdi till J
JOB SITE
APN
ADDRESS
79-61 t HIG ' A Y 111
FFa (l' �e1i1
OWNER
CONTRACTOR / DESIGNER / ENGINEER
SIXION FAMILY PAR7NE&SI IP
ROTO ROOTER
38611 US HIGHW, AY 111
696 N. STATE S-1".
LA QUINTA. CA 92253
KEIt P, CA 92513
(9()9)058-85<11 CBL# W60
USE OF PERMIT
iY0 i'1
SEPVC ABANDOW, CONNECT RIJUaD1NG ANIS CARWASH CLAWIER TO
C.i7"Y• SEWER
VALUATION 1.3,500.00 LS
•d.Si"IMAT.EDCOST at< F C-0NST-S UCI'1ON
a�,:'sSI0,9#gis
PDrRNI D' FE1✓+ SMI LAKY .
PLUMBING FIFE -r SEWER. 101-000-4.19-(H10
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Al CONS �UC1'IU�1 ANpl��3��sL�t�fNnC+.�nl
�SshJ.�A
g
pCf�i�� FEE'S
4E$S CIV' PAID FEE'S
iAU.111
AL PERMIT YEEIS DUE NOW
'fi3ii.a0
RECEIPT
DAT
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
Sewer Connection
= �f�j
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
�
�h✓_ih.s�
Final
Utility Notice (Gas) (
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures�
Main Service
Su
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Final
COMMENTS:
u ,J �
•
C)e
-
4PT!oll
AY Gp TR OUBLES..D_0_WN:T`HE pRAW®�.-
�:xSlnce 19351•�lWORK-ORDER NO.13094"'MBERS HEMET (909) 658-8541 ❑ LAKE ELSINORE (909) 674-2312
❑ BANNING (909) 922-9491 ❑ RANCHO/TEMECULA (909) 699-0555
Free: (800) 491-7686 ❑ BEAUMONT (909) 845-3338 ❑ REDLANDS/YUCAIPA (909) 797-8697
Fax: (909) 652-9515 ❑ PERRIS (904),657-9852 ❑ PALM SPRINGS/DESERT HOT SPRINGS (760) 322-2622
Remit to: 796 N STATE ST • HEMET, CA 92543 ❑ SUN CITY (909) 679-8919 ❑ INDIO/PALM DESERT (760) 346-1736
)
JOB NAME
S/
----------- ❑•
Z -n
r
JOB ADDRESS
CITY
TE ZIP
; 11• :
PURCHASE ORDER NO..
DATE � C:> JOB #
SERVICEMAN 1
SERVICEMAN 2
DAY GUARANTEE (SEE BACK PAGE)
MAIN LINE
----------- ❑•
BATH SINK -------;- ❑
FLOOR DRAIN -----
0- ACCESSED VIA:
CAUSE OF STOPPAGE: TIME:
FIXTURE
; 11• :
..
CLEANED: TOILET ---------------❑
�
`••KITCHEN SINK-------[:],
• FLOOR SINK--------❑
11
DRAIN ----------------- ❑
ROOTS ---- --------- ❑ IN
BATHTUB
--------:--❑'
LAUNDRY. ---- -----------
❑' "
AREA DRAIN--- -------
CLEAN OUT -------- [:1
GREASE -----_-----❑ OUT
SHOWER ------=-=--❑
URINAL --- =--------- --❑ "
OTHER .. •
VENT --- -------------- ❑
OTHER
PART NO.—
QTY.
DESCRIPTION PRICE
DRAIN CLEANING ( FT.)
ADDITIONAL FOOTAGE (" FT.)
_ADDITIONAL FIXTURES(S)
TRAP / TOILET REMOVAL
LABOR- =
VIDEO INSPECTION
MINI JET
HYDRO-JETTER
LINE / LEAK LOCATION
PUMPING G'[�Q ASS E /SEPTIC
CHEMICAL TREAT
CHEMICAL
OTHER
69s
Q6 -.l
�
Cn
PARTS TOTAL
TAX
TOTAL
❑ CREDIT CARD ❑ CASH ❑ CHARGE ❑ CHECK # /
CC #:
EXP.DATE:
AUTH. #
SUB TOTAL
CLEAN OUT REQUIRED ❑ YES ❑ NO
REPAIRS RECOMMENDED ❑ YES ❑ NO
ESTIMATE: �1
REMARKS:
t 7eQ—
PLEASE INITIAL THE FOLLOWING:
A. The serviceman discussed Roto -Rooter products with me.
B. I have been advised additional lines cleaned at this time are half priced.
►G. I have been advised that running my main line from a roof vent is improper access and can only be given a 10 day guarantee.
In order to get a 90 day guarantee a clean out must be installed. A two inch main line roof vent has a zero,, guarantee.
Division of RotoCo., Inc.
License Number: 422155 • Federal ID Number: 33-0475032
i CUSTOMER SIGNATURE
ALL SALES FINAL CUSTOMER COPY
DESCRIPTION- '
PRICE
DRAIN CLEANING ( FT.)
ADDITIONAL FOOTAGE (" FT.)
_ADDITIONAL FIXTURES(S)
TRAP / TOILET REMOVAL
LABOR- =
VIDEO INSPECTION
MINI JET
HYDRO-JETTER
LINE / LEAK LOCATION
PUMPING G'[�Q ASS E /SEPTIC
CHEMICAL TREAT
CHEMICAL
OTHER
69s
Q6 -.l
�
PARTS TOTAL
TAX
TOTAL
❑ CREDIT CARD ❑ CASH ❑ CHARGE ❑ CHECK # /
CC #:
EXP.DATE:
AUTH. #
1.
CONDITIONAL GUARANTEE
This is a Binding Contract - PLEASE READ CAREFULLY.
(Guarantee good 8 A.M. TO 5 P.M. ONLY)
For days from the above date, we agree to re -clean the above described line
(up to the original time charged for) at no charge - maximum 2 (two) repeat visits or refund money
at our discretion. Main line stoppages are guaranteed against roots only, and must have 3" or 4"
access. All other lines are guaranteed against normal build-up only. Stoppages caused by a septic
system, food scraps, rags, cement, other debris or broken settled sections of pipe are not
guaranteed. ROTO -ROOTER is not responsible for any damages caused by backups, faulty plumbing
or machinery. Customer is responsible for removal of lodged cables due to'separated or root -bound
lines. Customer is also responsible for any collection or attorney fees in regard to this invoice.
TERMS: NET 10 DAYS. A FINANCE CHARGE will be computed on the unpaid balance by a single
period rate of 1-1/2% per month, which is an ANNUAL PERCENTAGE REATE OF 18%.
"Under the Mechanics' Lien Law (California Code of Civil Procedure, Section 1181 et seq.), any
contractor, sub -contractor, laborer, supplier or other person who helps to improve your property but
Is not paid for his work or supplies, has a right to enforce a claim against your property. This means
that, 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 own contractor in full,
if the subcontractor, laborer, or supplier remains unpaid