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0401-416 (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 r�ofessionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date W21 r -:g6 B Signature of 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. ( ) 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 !s' RIAPIT Policy No. (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 if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions,. Date: Applicant • =-^tee;"" ..zL ��---*-•.-. Warning: Failure to secure a 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. PERMIT #^ BUILDING PERMIT, 0401-416 Ea VALUATION LOT TRACT �32/2.9not �sfl. o JOB SITE ADDRESS �i-i33ru����Au APN •OWNER CONTRACTOR / DESIGNER / EN (NEER •AM. AD VJQ'fMO 52-8Z5 AVEINJIDARAWREZ P.O. BOX 955 LA. Q}TT,XTA CA 92253 Y UCC AVA12 eff CA .92286 (763)'369.4101f CIX 6498 USE OF PERMIT P.TI T1\ PAM, VALUATION %ti.30160 .11113 EsTnW ED COY." OP' 00.3YNrIMMION P UDARYNO f ER -• fl!?WER 101.000.419.000 $30.00 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 with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. J. RECEIPT Signature (Owner/Agent)--Z7—'-�**""�- �"" " Date D �e,arn n, 2 9 2004 CITY OF LA Q1iINTA V—UB-TOTAL. C°OY,49U26:M',1011T Akt-D T-,! C ECM DATE .: V $30,00 $0.00 t+O) 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 P''maI 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) 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) ',CU4i GO LV VY 16: G7 1(V�V i f A. litl "VVl AWV.L1 DGIIAZU It—tiVO Z•VVG/VVG l .M--1}�^^. .. �...w.S.:^.�-,��. �..�Tf•�r-+—.+,..r,T.�,y�..�wr��.!...�r,,�.rT.�'��.r'r �ow�...w ew..��.r�+i.��}�.r!a•• ..^l^r��—rW�.r�!r!r!, .en. o n a o n.❑ ❑ o o ❑ o o oFL a �g � ? m y fA R, J4 14 HAMMER PUMPING INC. JOB INVOICE P.O. Box 2448 CATHEDRAL CITY, CALIFORNIA 92235-2448 f7ani �An-SAAR (760j 321- 7448 -} CUSTOMER'S ORDER NO. /?/ DATE ORDERED -.:� 9 0"-/ ORDER TAKEN BY DATE PROMISED ❑ AN. P.M. BILL TO � O � r� � - PHONE ADDRESS ECHANIC U � CITY HELPER Ng E f�D IeOgION _ ❑ DAY WORK •y ��+,/ ©✓ / �.GI i ❑ CONTRACT ❑ EXTRA 14 Ar ,.// Al r QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT Gallons U Pumping Fee per 1000 gal. j100 Dumping Fee per 1000jgal. a Out of Area Fee Locating / Opening Fee (per hour) 1 I Size System: �r 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 HELPERS Q TOTAL LABOR •' I hereby acknowledge -then Isfactory --.... completion -of -the above 'descn etY,workL.._.._ TOTAL LABOR T. TAX DATE COMPLETED TOTAL