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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 force and effect.
License # Lic. Class Exp. Date -
684563 A HA7, IM > 02/2
Date l3— '`�rOf Signature of Contractor �-' ✓�' .
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,
J90 have and will maintain workers' compensation insurance, as required by
n 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:
Carder. S'iA'dI"S Policy No. 044
01419298
(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 Califomia, and agree that if I shcutd become
subject to the workers' compensation provisions•,of`Section 3700"of the Labor
Code, I sh II forthwith comply+Wit "those provlslorps.
Date: 1 r;_i! *. i Applica�pt; ~.. �
Warning: Failure to secure Workers' Corfrpensation overage 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'authorize representatives o�f)this City to enter upon
the above-mentioned property for
r inspection purposes.
If
:�a�; Date rr � 7;✓3
Signature (Owner/Agent• ;o N.� - 1
BUILDING PERMIT PERMIT#
DATE ' VALUATION LOT �'� ^ TRACT
47
JOB SITE
PN
ADDRESS 1ww, Wn mmaisn
64&311-047
SER
CONTRACTOR/DESIGNER/EN INEER f
}/�, /��5{s'�,� ,Q yy gg[�jy (�y/ 'n� /` J��, ��jj /'� (!'• �� 'yf^��''• ]] ��--ct
SY',4.14.. C.C11,7L'WIL J:�(1�711.CCO LJIii,Cd . 4`,
yyY ��.) �^.'{ '�� �,�`{ (��'['1'�'1��,�,r/�, /^�9�'(�;��
d,✓.L'Y.i�QLJt�Y.+AS •Ge1LV Vl±.�S.Gi.LS�M1 40 & COWTF,.: .
15-540 B(Yf=r6RT).0H DkUVE
4575 R CAMNO PAROCIE' A
LA QT..133 A. CA 92253
PAL IVB �'VRWGS (7.A. 92264
5 �� -1'1 r8 O
(M)W-2700 MIX1. 3577
s
-- -- -
USE OF PERMIT
;�ir.�2'>iC A.B.i.Fii�ik7C/?�, S�3"Lo.83, P��3C2Y•GrP SfaC.3®3'oIVdCJB.� }�.8.0:6'!�C"E'�:,(t?it,l . � NOV: 200'
V
t
.•�
axer ^re l Ant 1114TTA4 "
VALUATION 1.10
WWWAiED COY "OF 0101,49 "RUCIDI DN
2;MAM
Pi ,d` YET EMWWRY
PLLiMB1140d-EE x°01-000 4419-000
SUB-'f;C)%AL COa` VRIT ~ 7".tM A,MID X AN CRECK.
$3lMlol
1MYS :PRE -PAID F1 -S
rY. aYf .l].a F.f P-ra ''i.V,S ,11-K EN DIVE, ,111..EYI
yyi:.�lJn1f1I
RECEIPT
DATE /
BYF
ED
INSPECTOR
fl �A r i
195
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set B cks
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
ewer Lateral
,Sewer Connection
Pool Cover
Encapsulation
Gras Piping
Gas Test
Appliances
4
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:
HAMMER PUMPING INC.,
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
(760) 360-7448
(760) 321- 7448
81LL TO
ADDRESS
CITY
J400 NAME AND LOCATION
C1ESCRIPTION OF WORK
Gallons
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
JOB INVOICE
CUSTOMER'S ORDER NO DATE Q
ORDER TAKEN BY DATE P
PHONE
A SERVICE CHARGE OF SZO WILL BE DUE
ON ALL RETURNED CHECKS.
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUNTS OVER 30 DAYS.
I10URS L_A6DR AMOUN r TOTAL
cQ
MATERIALS
MECHANICS
TOTAL
HELPERS @
LABOR
I hereby :.cknaw1edgc she}allsfr ctary TOTAL LABOR
TAX
ccnpletiou ref 111e abate derk,
51C.�lATIJRE _ DATE COMPLETED
TOTAL
L -F
❑ FL -
DAM
❑ P-M.
>i /
DAY WORK `
CONTRACT 11I
I
I .I E %T RA
AMOUNT
I