0308-149 (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
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:
(V,) 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).
O I,am exempt under Section , B&P.C. for this>reasop—'
"...
Date 4'O 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.
(Thissection 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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Codel shall forthwith comply with those provision's=
,�te:
Applicant
. _�.� ,,• ",
r A��• _r^
Warning: Failure to secure W65kers' 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
the above-mentioned property for inspection. purposes.
Signature (Owner/Agent );✓=+-�- '%��° Date
- PERMIT # "^
BUILDINGRERMIT .. <►
R,
tt
DATE ti VALUATION LOT TRACT
JOB SITE
ADDRESS ^ �:Cs' ai}1.� i
APN -
OWNER -
CONTRACTOR / DESIGNER / EN (NEER
�..}'�'�t:.}}� � �.�3w''�il ailt.f���
S3S�liL�:'A: -• ���.���L.;�. ,
i
USE OF PERMIT j
l
Ytl:UJ.AT1r,`H a s 40010
I'.Ull D.KKA.IVE' _- ;� v �F;. i '. -C? c�. � c. t"y� �h� t►0
° AUG 12 1003
CITY OF LA QUINTA
FINANCE DEPT.
°�A'e%'�4'a'�.,
.- jt';,�r�¢���'
PRE
9 t 4�rg�47+,�.�7.•.:�c�.�y SpA �y�
Aa4YT�ted.°:iiq.�Li.}3Ad JOi,.-'r�i,��1,7%W,�,l.�f 9i/'HY
6�f��`�,(P,a1`>�3
RECEIPT
DATE /
BY
DAT D
INSPECT0
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
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 r
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
fewer Lateral _
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
"
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)
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL ma aAIQ9.11
f
4 Al
Received From: L—
Address:
Account No. ` Lot(s)
Service Address r �` "'( �^ = • L -j
O Meter(s)
❑ Service(s)
❑ Backflow(s)
O House Laterals)
❑ DetectorCheck(s)
❑ Meter Surcharge
Sanitation Capacity Charge C7
'r
❑ W.S.B.F.C.
❑ Temporary Construction Meter
�• ❑ Turn on Charge
❑ Uncollected Account - Name
❑ Inspection Fee -Tract -
j Fee -
❑ Plan Check Fees Water ! Sewer -
` Tract -
j: ❑ Bond Payment - A.D. - Bond
t:.
t Assmt.
❑ Customer Deposit
f=
C) othAr
G.A. Code
$
`f ✓ t r II i ;` TOTAL $
4 Remarks:
rr
,
�C py to:
r- h
Cash t Water Service_
; • ,
-,. Check
k.
Money � � ,. � +r �;:- Cashier
Order 3A ' CVWD-438 0
4 r-.
HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
f Ism -Un - 7AAR
i760)321-7-4-4-8-
760) 321- 744:8
CUSTOMER'S ORDER NO.
DAP ORDERED
c3
ORDER TAKEN BY
DATE PROMISED ❑ A!M.
❑ P.M.
BILL TO
PHONE
ADDRESS
ECLIANIC
CITY i
HELPER
`TI
JOB NA^/7/ME AN .3CA
❑ DAY WORK
CRIPTIO OF/N�'ORKyy / �J �^r ' A^`
! �/ ti� .6 /D•' / !/ O✓ " L �� r �'
❑ CONTRACT
O EXTRA
QUANT.
DESCRIPTIOW OF MATERIAL USED
PRICE
AMOUNT
®�
Gallons
Pumping Fee per 1000 gal. ' �(/"
I c1 4
b
Dumping Fee per 1000 gal. !
S
�-- �.
4
Out of Area Fee
Locating / Opening Fee (p?r hour)
Size System:
+�r
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUMTS 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
I
[�