0012-204 (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 foece and effect.
License # Lic. Class ;�_� Exp.D f/y
614561 AB
4
ate ~-Gk.}Signature of Contractor
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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).
O 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. -My workers' compensation insura6ce ;carrier & policy no. are -
Carrier Policy`No. ` ' '
STATE IWD
(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 agreV i if'l should-pecome
subject .to the workers' compensa ltlt on provisions oVSection 3700fo�he Labor
Code, (shall fortjpwith complywitNthose p ov sioris. l r '3�r
Date: f<-,. f ` it to APplicanf".c:a /6. � , ,i + •`r
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,Odb,.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 withall-City, and State laws relating..to the building
constri�ction, and hereby pthorize representaative's'of this dit� to enter upon
the alSove-mentioned property for inspection purrposes.
gature (Owner/Agent ,..� .r ��"%y�l te( ` ate
BUILDING PERMIT PERMIT #
DATE VALUATION LOT 0012-1(. dl TRACT
qq aa pp��gg��
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
tAR-)1q i RM;0 AND MANA-CH12
DFIABO MOW MG & COASM
51`610 IN.LR
66- 15DEMOS COURT
LA QUMT.A CA 92263
C AT =+ 1' Cf.:CN' CA 92Ts4
M, 3$77
USE OF PERMIT
:r�,,UMMI NCi
SEPTIC ABANDON • SEWER. C0.4 -M. -T, 1,i3'W-140D.P4?QJY.,CT 2=41. "
VAWATIMI 1z
IILUMI.Ifflo ITE, OEM 101-000-419-000
-000
SUR -TOTAL C±CN&MUC°11 ON AND 1r`lL.W C ECK
$30.00
LM, P'k •:a.AZCy VMS
$0.00
RECEIPT
DATE f y
BY
DATE FINALED
INSPECTOR
I{
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
POOLS - SPAS
BLOCKWALL
APPROVALS
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
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) 0�3 B/ S
/
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.
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
17r,m zan _ SAAR
JOB INVOICE .,
1. —, — . -..+
(760)321-7448
CUSTOMER'S ORDER NO.
DATE ORDERED
/- 1 5-- p C
ORDER TAKEN BY
DATE PROMISED ❑ A.M.
'
❑ P.M.
BILL TO
�S —�
�• S
PHONE
ADDRESS
Dumping Fee per 1000 gal.
MECHANIC SS
CITY -
HELPER
J NAME AND LOCATIN
'
DAV WORK
O.
DESCRIPTION OF
CONTRACT
❑ EXTRA
Locating / Opening Fee (per hour)
S
/)
Size System:
-
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
r o.d 6
Gallons
Pumping Fee per 1000 gal.
�S —�
�• S
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 Q
TOTAL
LABOR
HELPERS Q
I hereby acknowledge the satisfactory TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE
DATE COMPLETED '
C O (
TOTAL
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W.
4111
' Mar 02 01 07:25a Tri Star Cons. 7603217798 p.2
' .... - (7emstruction. & Excavatinn
"We dig the Coachella. Valley"
y
Date: Z_ — Z -- 6
.Address:
I, the undersigned, hereby accept the above listed lot, as is, following the septic to
sewer conversion.
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Owner Signature
wner'Prinie4NamC!
Bus (760) 321-0898 P.O. Box 542, Cathedral Cit);, California 92235 Fax (760) 321-7798 .
e-mai[-TriStarF-xcavate&oL com
03-02-01 07:17 RECEIVED FROM:7603217798 P.02