0110-215 (PLBG)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:
r t91
DateSignature of Con.."A.
OWNER -BUILDER DECLARA7'1ON
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.
I have and will maintain workers' compensation insurance, as required by
ection 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 ,y'd 3° 11mPolicy No: ft44 {j2 i1�2d
(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 that if;l should'become
subject to the workers' compensation provisions/;fSection 3700,- the Labor
Code, I shall forthwith comply,4itla those provisions.?
Date: 1f-"' Applicant
Warning: Failure to secure Workers' 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 thiPCity to enter upon
the above-mentioned property for inspection purpose's.,r
3� , J
Signature (Owner/A4bnt)��zWdeN, �a "Date /_/r
BUILDING PERMIT PERMIT#
DATE VALUATION LOTTRACT
l i �"x Ca. / r,i
JOB SITE APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / ENGINEER
UR 4- hr s. ;tFAk3110 GMr'RREZ DENW1;;F?,WOMER O & COMIr.
51.410 (.IPIUM(IL0 45115 X CARO :k`'AROC"EIT
USE OF PERMIT
PLUMBWO #
SEPTIV-1:f3. NNDON, SLIWYR "HOOK-UP (WW- 440D PRO:t.E't'
-WOMMEW COST OF CONSTYM(TrION
PERMIT F12 9UNWARY
$'6'MM1 O Fit 101 -000-4,19,,000 SAN is
S► Tib-WTIAl C"ONVIIR07�`.` 09 AND PLAN MIX -M. $30.00
ism PFIYII�PAM rMll $0.00
MAL PE -W -Tr VIM ME NOW IM00
RECEIPT DATE;,% f BY DATE FINALED INSPECTOR
1 I a F,,;
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 Wali Insulation
Condensate Lines
Party Wali 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 Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shrover Pans
Q.K for Finish Plaster
/ Sewer Lateral l—
Sewer Connection- U' -
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
THS QIP 0 Z_
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. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
17m Qan _ 7AAQ
i7'6 -0-i3-2-1--7,4'4"8-
760) 321- 7448
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE ORDERED
p�
Gallons
ORDER TAKEN BY
DAT PROM SED 0 A.M.
Pumping Fee per 1000 gal.
0 P.M.
BILL TO
PHONE
Dumping Fee per 1000 gal.'4
A0�
ADDRESS
MECHANIC
CITY
Out of Area Fee
HELPER
JOB NAME AND LOCATION
0 DAYWORK
Locating / Opening Fee (per hour)'
DESCRIPTION OF WORK
0 CONTRACT
2c,
Size System:
� �
0 EXTRA
IV
< —
B
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.'4
A0�
Out of Area Fee
Locating / Opening Fee (per hour)'
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 Q
TOTAL
LABOR
'
C
I hereby acknowledge the satisfactory
completion of the above described work:
TOTAL LABOR
TAX
SIGNAT RE
DATE COMPLETED
o /Q a2
TOTAL'
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