0210-159 (PLBG)E t:, _ LICENSED CONTRACTOR DECLARATION '
I h1reby affirm under penalty of perjury that I am licensed under"provisiohs-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
47 51S ABMC 0513€3/2f
Dater Signature of ContracCor
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 they, 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 STAT& FUND Policy No. 041.02-0019792
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certifj'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 sh If fort ith comply with those provisions.
Dates ✓> Z•Applicant� i
Warning Failure to secur dWorkers' 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 suchl
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.
Signature (Owner/Agent•) �f�''�----� "'"J - Date," i
ell .
BUILDING PERMIT PERMIT"
0210-169
DATE "'" VALUATION LOT TRACT
JOB SITE
ADDRESS l 765 A E..1M?4 K. Z
V
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
k4Z bas. EvhWIPM0 R., MOS
M SAR Cr01�i�-[RUM034
54455 AVE. RAIVMQZ
34130 TEE PALM DME
LA tl't.Y,t rrA . CA 92233
CA11-T�tt:l�RAL C fY ICA, 92235
(760)3.. s -OFS s CsLdt
762
USE OF PERMIT
PIL UMQ13190
S.ZP TIC ABANDON, SEWER HOOK-UP 0,0W.MOD PROJIMCT 2002.01)
VA3..t1ATION 21500,00 LS
E57MAM' C 0b7 OF C0X9k.VU J0fi
4500.00
]PERIMT FEE SUMIARY
PLUMBI O IEE l sai 4000-419.000 $301.00
:l'I;i"£v-TO'YA1., F CWT! 4 U{.'i�C) l did ]�S�t�.�! MIRCK.
S3ta:00
Oe U7,83 M-11AM QPM
MOO
1.11MUM FIMPI; ME NOW
OCT 2 8 2001
WYOF(gQUINTA
FlNANCEDEPT. �
,:.
RECEIPT
J.DATE / BY"! I
/
DATE FINALED
INSPECTOR
7
L
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
Pool Cover
Sewer Connection _
Encapsulation
Gas Piping
Gas Test
Appliances
✓�/L /��
Final ._
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)
COMMENTS:
RAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
itian► Zan-7AAQ
DANT.
7 4
(760) 321-7448
CUSTOMER'S ORDER NO.
0 TE ORDERED
-/ I - v
1 0&a
Gallons
ORDER TAKEN BY
ATE PROMISED ❑ A.M.
WO
Pumping Fee per 1000 gal.
0 P.M.
BILL TO e—
S
PHONE
ADDRESS
,
S
MECHANIC
CITY
HELPER ,(J
JMAN LaA?N
_ C �-
- aG✓1 Com. L
AY WORK
DESCRIPTION OF WORK
rC
CO RACT
.E RA
Locating / Opening Fee (per hour)
C:
<<L
Size System:
DANT.
DESCRIPTION', OF MATERIAL USED
PRICE
AMOUNT
1 0&a
Gallons
WO
Pumping Fee per 1000 gal.
O,d
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
<<L
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
18% PER YEAR VIJ(LL BE CHARGED ON
PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR I + AMOUNT
TOTAL
MATERIALS
MECHANICS
YELPERS
TOTAL
I rPbby ack owledge th satiSfaeto'i��
ompletion%o the aboyea SCribe'd work:
TOTAL LABOR
TAX
SIGNATURE
DATE COMPLETED
013 O.�,
TOTAL
C I d
R�