0210-150 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Clpter 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
DateA` ✓ "'L 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).
( ) 1, 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 STATE j %1 -ND Policy No. 044-02.00IMP
(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 anyperson 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 II fort 'with comply with those. provision ti
Date" Applicant ate` -'! ..a=-.•~ ^~-~�-e.-.
Warning: Failure to secure,Workers' Compensation coverage is unlawful and
shall subject an employer t&'6iminal 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 coriditions 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.
Signature (Owner/Agent)"%1 /' / - �^""Date �' 1
PERMIT #
BUILDING PERMIT
0211.04fX)
DATE / VALUATION,f LOT I4TRACT
JIOB SITE
ADDRESS !%r°��} a��. o�'P
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
W. Nt:iFtMA 913B r3A ,Y
`MUMR C« 4Krrt`f 1CJ—I:0y3'
32.39(1 AM J1.7ARRZ
3473 D IDJUEs PA:i,IA L'iRMB'
LAQila-"M CA 02233
CA T ZZRAL C-ItY r'A 972-3
(760,321-089S CM4 762
USE PERMIT
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PLUMB= Ci P119 101-000-41R-000 430.00
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$30.00
LEN Mi -PAM FRE,
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$0.00
MAX)
OCT 2 a 2002
r
AQUINTA
CITY0F .
FINANCEDEPT.
RECEIPT,
DATE A'BY
DATE FINALED
IN
V ''
ZZ
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
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
Final
COMMENTS:
Final 7_
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) j
1)
u
N
HAMMER PUMPING INC. JOB INVOICE
1 P.O. Box 2448
CAT"IiEDRAL CITY, CALIFORNIA 92235-2448
earn -qan _ SAAR
Ci (760j 321 -7448
' L
CUSTOMER'S ORDER NO.
DATE ORDERED ` O
ORDER TAKEN BY
D//A11TE PROMISED ❑ A.M.
❑ P.M.
BILL TO f � ('�
1/ J
PHONE
_
ADDRESS
ME(YSNIC t
L"ACITY
HELPER v
10131,VU JD�L:.00ATION, V e
SUL C• U
\
B1DAY WORK
DESCRIPTION OF W —�- /
CONTRACT
❑ EXTRA
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
LOQ O
Gallons
O o p
Pumping Fee per 1000 gal.
d Q v
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
�( -177
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
completion of the above described work:
TOTAL LABOR
TAX
SIGNATURE
DATE COMPLETED
f Q
TOTAL
t d
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