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0012-208 (PLBG)LICENSED CONTRACTOR DECLARATION 'i -hereby affirm under penalty of perjury that I am licensed under provisions of k 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 6+ 45623 AD F .E...,w ©ate I.? { - t=� j"Y� Signature of Contractor L J ±.. OWNER -BUILDER DECLAR TION• 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&RC. 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: Canicr Policy NO.:.-. STAT FU - G94-pg��ili.224 (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-thai'if I should -become subj�dt to the workers'. compensation provisions�6 Section 3700ro the Labor Code, I shall forthwith comply withrthose provisio . / ' Daae: L f t /fJ Applicant�ti s s'�. G .._ Warning: Failure to secure Workers' Co ensation 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 Se6tiori•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 Ouinta,, 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 permitto 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 aUihod'ie representatives of -this City to enter upon thelabove-mentioned pr pperty for�r inspection purposes � ,Signature BUILDING PERMIT PERMIT # DATE VALUATION LOT - j5�12-2(* - _) TRACT . JOB SITE APN b yy�.�. ADDRESS * yy�y MMA .1- R� 1Ct.. V 3:'.dRlt A JII ,L Z. 1 da7",Y.6`�••QNJ�'. OWNER CONTRACTOR/DESIGNER/ENGINEER VEL ASQUEZ AND ROSA1:1�. Y. A DENROM FMINDi-'1"<.W G & CONW. 51.730 AV!MP, ?� -1id ?" COURT C. LAQUI TA. C . 42253' Cis t�;i�.DIZ. �., f: CA 92224 (760)32.7-2.200 CI3I 35T.7 USE OF PERMIT a?r.cr�xa�rC3 SF.FVC AD.F NDO14. SKWER Cr.J`NhiP ..t°. LOWw3ySOD PROJECT 2000-21. 'J1#I.LiKCION ?,$00,00 Lo COASOF 01P WI�A{�9d1lCGYib�d.7f.'l✓e40 &Sl7v"h.�r4�7 ��yyyy- ��.qq;; +�� �yS��gi:,i�Rali,L�d04�:i.ED ftTWr*7 1�,�1i45G 8 . PLUMBING R- =- STW ER 101.000-11943+ut) � 3fl.itSi SUB-I`C9`.1'AL CM41TRUC1309 ANT) Pl" CTU? X $30.00 MOB :ESI PATD ?+TES, $0.00 RECEIPT DAT`E., fw.J yJ BY { j DATE FINALED INSPECTOR V 4 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 POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Undergfound Pibg. Test Final I I 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 �Q S Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final R-9,67 3 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) •/ HAMMER PUMPING INC. ; - JOB INVOICE P.O:-Box 2448 CATHEDRAL CITY, CALIFORNIA 92235-2448 r7#;rn -qan-7aaA ars (760) 321- 7448 CUSTOMER'S ORDER N0. DATE a ��-OR ED - O r—, ORDER TAKEN BY DATE PROMISED 0 A.M. ❑ P.M. BILL TO PHONE ADDRESS' - _ NIC r MEkv 4. CITY HELPER JOB NAME `AND LOCATIOlt v `r 3 G/r/� AY WORK DESCRIPTION OF WORK LA� O CONTRACT C] EXTRA4A G QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT 060 Gallons 060 Pumping Fee per 1000 gal. K = Off CI06 Dumping Fee per 1000 gal. 14) v Out of Area Fee Locating / Opening Fee (per hour) ©1'�frt cr 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 HELPERS @ TOTAL LABOR I hereby acknowledge the satisfactory TOTAL LABOR completion of the above described work: TAX SIGNATURE —F SIGNATURE DATE COMPLETED r' ® ( TOTAL,