0206-009 (PLBG)LICENSED CONTRACTOR DECLARATION
.I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is,in4ull force and effect.
O M License #iL�ic. Class Exp. Date
t` UJ � 3482 L +3,6 i I % f esC
oZ r- Date /�� . Signature of Contr cto,� +,e _ `.°1 � {
(VV
O 0P�
J U C:) OWNER -BUILDER DECLARATION
WWW I hereby affirm under penalty of perjury that I am, exempt from the Contractor's
In License Law for the following reason:
Z ( ) 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). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed FILUAE:E ING
contractors to construct the project (Sec. 7044, Business & Professionals
Code). . SEPTIC .l RAR
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 02106 -ow TRACT
524=AWr4il ARAdW1.Y�2.
5240 ? AMM,A RAW.M.
.M.LA QUINITA CA 92153
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.
()6, ' 1 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:
Cartier Policy No. F"r
.rR 1�?a8o)(11.
(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 )hat if I should become
subject to the workers' com`pe setion provisionsyof Section 3700 of t 4e Labor
Code, I Shiaa ffo�rthwith comply wit thjose pyovisi ris'
Date:' Applicant d/ .fl of
Warning: Failure to secure Workers' Compensation coverage is un awful 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. 4
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 complyewith?all City, and Statellaws relating to the building
by
construction, and hereauthorize representatives of this Ci y�1to enter upon
the above-mentioned grope y •f721spectio pur oses.
3lgnature (Owner/Agent)_ �/at'ee—
APN rt w
CONTRACTOR/DESIGNER/
-72,773 RA -40M RD, ,
ITIOUSAND P.;MS CA. 92276
ClFfl)34-4.2.2 4. CMIA 649e
U00100 LS
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P37: 49; .1mr L3 31t zPLUMB= FEE — OMER 101-000-419-000
RECEIPT
�p�U1@1i�►Of
Mal YYRR-PAJD:RrKte,*l
DATE FINALED I INSPECTOR
3101MAD
:4a}.00
ih010n
$300
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 8 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 Q
Pool Cover
Sewer Connection 6— - p Z --Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) Z
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:
COACHELLA VALLEY WATER DISTRICT
i
CASH RECEIPT DETAINo
L
004,
F .Received From. � � ' <j � it ! � l bt•: (.• t r.s• ., I_. 1.
Date:
(` Address: 4! :_r • :.:. - \!! t :'a':4. 1 �i'•. v^ , - ; �`t(, a �'(.l ��r �r /,�
[) Account No. 1 .L!t (+%. t w,
"Lot(s) va " ��: Tract 1 , c,'t:
(; Service Address
I G.A. Code i
! ❑' Meter(s) l $ I
� ❑ Service(s) r
{ ❑ Backflow(s)
❑ House Lateral(s)
_rr ❑ Detector Check(s) `
l' ❑ Me erSurcharge j
i Sanitation Capacity Charge
U.
E ❑ W.S.B.F.C.
❑ Temporary Construction Meter
r
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee - -
l
f; ❑ Plan Check Fees Water / Sewer - ,
= Tract - _
i' ❑ Bond Payment.- A.D. - --Bond j
k R
Assmt. -
t ❑ Customer Deposit
F ❑ Other
i
)
-
TOTAL c_� rs__' t
$ I! . y� {
Remarks:
r
j t7`60py to: r
) Cash' C.::., '• - •
WaterService
Check
Money c; i
c Order. ti Cashier
',; 2H ��V
i :. .. , .:. __, :. . �..:. .• : -. _,. . _ .. ,._.,.... _ ..,,.. ,..... ,,�:, ;. CVWD-438(11/89)
HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448 ,
` CATHEDRAL -CITY, CALIFORNIA 92235-2448
if VVI- VVV - ITTV
,76�I 31211-7448
�� _ ����
. '
CUSTOMER'S ORDER NO.
DATE ORDERED
�i `d oL
ORDER TAKEN BY
DATE PROMISED 0 A.M.
BILL TO� � ` // � C
PHONE
ADDRESSL I
MECHA C f
�,•LI/
CITY ". -
HELPER
JOB NAME AND LOCATION _
O 40
0
l`�``J
�-
0 DAV WORK
0 CONTRACT -
DESCRIPTION OF WORK-J� - - -
/O(!�J C-!
❑EXTRA
QUANT.
- -DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
�8
Dumping Feeper 1000gal.
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
completionofthe-abovedescribedwork:
TOTAL LABOR
TAX
,
SIGNATURE -
DATE COMPLETED
TOTAL
kct 0
_
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