0311-203 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chaptelr9 (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
?934.82 C16 B • Cf4P�0l�C
Date 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
cbniractors to construct the project (Sec. 7044, Business & Professionals
Code).
() , I am exempt under Section , B&P.C. for this reason .
Dated ';'—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 Policy No.
(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, become subject to the
workers' compensation laws of California, and ag"ree that if--I'should become
subject to the workers' compensation provisions of Section3700 of th.e Labor
Code I shall forthwith comply with"those provisioris,:
'Date:/- , 1/ .1111 Applicant '� l % /��°"'� /✓ " sr y !a, w
Warning: Failure to secure,.,WorkeYs' 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 authorize`'representatives, of this City to enter upon
t he above-mentioned property inspection purposes.
i
v fSignature (Owner/Agent ✓4 ='� �' !'� •--'`� � >'✓� Date /!• .,;r • �
PERMIT #
BOUILDING PERMIT -- �-
DATE AVALUATON LOT �i.,-2e� - TRACT
JOB SITE
ADDRESS}. AVt,
qPN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
YUCCAVALLEY CA 92286
Q60)369.4I04 C'B110 .6498
A•
USE OF PERMIT
Fl.013S q().
SEPTIC C:ffC. ;
VALUA'r ON Ls
RMAMIMD CWT OF CONSTRUC110N
51771.00
PERWT IEE s'►i1V. ARY
.PLUM81110 KE -- SEWER 101-000-419-000 $30.00
,
NOV' 19 2003
CITY OF OF LA ®UINTA
'I FINANCE
1 P7:
g'6T$-TOTAL CONSTRtl't" M014 AND PLANT, C'MC X
$30.00
- LESS PREE-PAIIa HIM
$0.00
TOuli- �*AWIVa.1.'X' FM buz NOW
00.00
RECEIPT
DATEBY
df,w-' 0 )
`
DATE FINALED INSP TOR
- t o.�'.
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
OX 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 Unes
Heater Final -
dater Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure.
Shower Pans
O.K. for Finish Plaster
tewer Lateral bol
Pool Cover _
Sewer Connection QIL if AvEncapsulation
Gas Piping
Gas Test
Appliances /
IL 2 < 09
Final -
Final L
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
!Jnderground Conduit
Rough Wiring
Low Voltage Wiring
Vixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS
Received F
Address:
Account N
Service Ad
❑ Meter(s)
❑ Service(s)
❑ Backflow(s)
❑ House Lateral (s)
❑ DetectorCheck(s)
❑ Meter Surcharge
sanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
• Tract -
❑ Bond Payment - A.D. - Bond
,r
Assmt.
❑ Customer Deposit
❑ Other
f
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
9 9912®
•Remarks: ) 9 A \'Yah
❑Copy to:
Cash - �"� ; t ,. :•.
Check�yl
Money` `
Order " t
. _.. � .. ... . . ..•tis , �o.-_�: .. K:�`, �. ... .. .. ... .,_ .. ,. ...,.... i.'� ..
WaterService f r
Cashier
CVWD-438.(11 /89)
HAMMER'PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
17m 4lan-7AAR
i760i321-7448
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE ORDERED
Gallons
ORDER TAKEN BY
DATE PROMISED ' : A. M.
P.M.
BILL TO V
PHONE
Dumping Fee per 1000 gal.
ADDRESS,- x_ _.
MECHANIC
_
Out of Area Fee `
CITY
HELPER
JOB NAME AND LOCATION
Locating / Opening Fee (per hour)
7 DAY WORK
DESCRIPTION OF WORK
.77 CONTRACT
Size System:
i
EXTRA
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.
Out of Area Fee `
Locating / Opening Fee (per hour)
Size System:
i
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 Q
TOTAL
LABOR
I hereby acknowledge the satisfactory TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE -.-
DATE COMPLETED
TOTAL
,.