9612-002 (PLBG)LICENSED CONTRACTOR DECLARATION
U 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
CV �, j-i,Tofessionals Code, and my License is in full force and effect.
Z) ch License # Lic. Clas'si-`" Exp. Date
r C) LO :1733-1 1� 6_3 W31196
T+o{ Signature of Contractor r
Z � Date � � + � ; � •
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U OWNER -BUILDER DECLARATION
WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
to 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
C'') () I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner
0)CL Q WORKER'S COMPENSATION DECLARATION
C:) Z tr I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( I have and will maintain workers' compensation insurance, as required by
O U Section 3700 of the Labor Code, for the performance of the work for which this
d L Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier 5.l tl"t F; Cft:�i; 7 Policy No.
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(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
3 subject to the workers' compensatid provisions of Sectio 3700 of the Labor
Code, I shall forthwith comply withpthQsp provisions.
Date: NV 7 fG t— Applicant rrty Vb
tJ
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 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 a'uth—o-fte representatives of this City to enter upon
the above-mentioned prop rrty,for inspection purposes.
Signature (Owner/Agent) I -*" Date ' "�' �.C;
BUILDINGPERMIT PERMT# °°NTR°`#
4395DATE ,tZI ?iI�1Ql VALUATION LOT: LOT' TRACT
JOB SITE ;�I�AV11V.�.i�IO.�!,.i�lEs APN
ADDRESS
OWNER CONTRACTOR/DESIGNER/ENGINEER
X3140 A:Ui':`1+3tiiAU,t�IOZE7, 5E-0011.13SENHGVR ;lilt.
1A Qt.JWA. CA 9x253 LA, QUINI-A CA 922,",
{iiiJ3?fial-73311 CBLq 2526
USE OF PERMIT
ad�;tAltitl, t:.it:li,DT�t!!' X1;1+t'.tG,:' i4i1;Vt�U.
CONT11i11Ci' 1.060,00 (,S
4 } �q{I� pp,,��- ♦ y�'g..}s'l".i11 .rA1.�1..i'f �`+�N Or, t�(.)N,STRUC ION' - .`ayi)ri'0.U0
FEE �i>i',iIY9SY,ik" RV
PLLIfv1131't (1!703.—SEM-A 101-000419-M) �3+iA0
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LUSS .111 '1'AID I=SIS $0,(H)
'iii TA►L $'Ei2Mff Fi+.�',.S flffl., NOW
RECEIPT DATE 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
Exteror Lath
Dryv4.1- 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
Shawer 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)
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From--14�\ � ,e f, �. Date'
Address:
Account No. 6Q6,Y / Lot(s) Tract
Service Address _f2 -/UZAL 1 J I A Q, G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
%❑ DetectorCheck(s)
l
❑ Meter Surcharge _
�- �nitation Capacity Charge Ste; -
J❑ .W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
-❑ Uncollected Account'- Name
,O. Inspection Fee - Tract
Fee -
❑ Plan Check Fees Water I Sewer -
Tract -
❑ 'Bond Payment - A.D. - Bond
❑ Customer Deposit
❑ Other
HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448�—
CATHEDRAL CITY, CALIFORNIA 92235-.2448
360 7448
(61.7) -
(619) 321-7448
CUSTOMER'S ORDER NO.
DATE. ORDERED
14— — Q
ORDER TAKEN BY
DATE PROMISED ' 0 A.M.
0 P.M.
BILL TO r-.�
PHONE
ADDRESS
ME NIC - t I
V
CITY
HELPER
JOB (�N'A�fv�EZ AND(,L/OCATION n ,yam /
_J J l
2'6AY WORK
0•CONTRACT
0 EXTRAJr
DESCRIPTION OF WORK C �� // /
t� -�. ✓ / ` `("�w^l /
('�
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
I S�
Gallons
00 Q
Pumping Fee per 1000 gal. r
8
cy n
000
Dumping Fee per 1000 gal. j X
S -b 0;
sc—a
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
K5i
A SERVICE CHARGE OF $20 WILL BE DUE
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 cQ
TOTAL
LABOR
HELPERS Q
I hereby acknowledge the satisfactory
completion of the above described work:
TOTAL LABOR
TAX
SI NA -U'1 E
DATE COMPLETED
�� (�
TOTAL
13 S
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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 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 contractor in full 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 they are 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 suppliers through
a..joint control. Any joint control agreement should include the addendum approved 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 payment
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 improvements 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 oohstruction 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.