0012-210 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
f;L'hapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
Licepse # Lic. Class Exp.- Date
1t���:lV
bate ' I Signature of Contractits
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
Sec 'on 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.
STATH FUND 044-0-001217:0
(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 I should become
subject to the workers' compensation provisions of Section 3700 of tie Labor
Cpiie, I,shall forthwith comply with those provisions
Date: ' 1' f:)ku APPlicantll)_, .cl-el d`._• /J
Warning: Failure to secure Workers' Compsation coverage is unlawful and
shall subject an employer to criminal pen�ties 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 inspections rposes.
Signature (Owner/Agent),e Date �'JC
BUILDING PERMIT PERMIT#
DATE VALUATION LOT' TRACT
JOB SITE
APN
ADDRESS
5x-04..5 AYV.YND) A. V0tf4►gC!0
` 1
773-0&1-113
OWNER
CONTRACTOR / DESIGNER / ENGINEER
RTC ARDO V7dG A AND GARR.l7xAI:RRANN1
0. Du'?;rBOM ENC1.19141RIN :i & CONSIT.
51.045 AV1'0 AVU_,X5 'i=
68.375 DE". .8 COU'KI
LACl'UINTA CA 92253
CAMWRX,C."T.'FY CA. 92234
('160}327.3200 C23Y* M7
USE OF PERMIT
v
PIA MBING
S..PTIC Afi.Rl+fDON • St"51 ER. CONNECT. Low -MOD PP.O11rcrr 2000.33.
V'ALUA'TION to
i��r"MATED C09r OF COP' UC.. -MON
SAW -00
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A-l.I�IlM131140 X,4'.E i.'i3.}7T�FR 101.t1t —41.9-000 SX00
SUB -TOTAL CONSTRUcMON AND P M' CMCrX
$130.00
LESS M -PAID IMS
30.40
RECEIPT
DATE,
BY
DATE FINALED
INSPECTOR
Y�
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
t F.A.U.
Framing
y Compressor
Insulation
Vents
Fireplace P.L.
I Grills
Fireplace T.O.
j Fans & Controls
Party Wall Insulation
1 Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
— g • 0 /
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final 3` D57
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
HAMMER PUMPING INC.,
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
/7Cf%% 9CA _ 7A A 4
JOB INVOICE
QUANT.
(760)321-7448
'
CUSTOMER'S ORDER NO.
DATE ORDERED
ORDER TAKEN BY
DATE PROMISED 0 A.M.
❑ P.M.
BILL T•q/��•
Tr
d -
O C3 v
PHONE
ADDRESS —
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cjo
MEfjkfANIC
C//� W
CITY
HELPER
JOB NgMI 0
YS— � �
� �^ �
V S O
IOC
AY WORK
I
DESCRIPTION OF WORK
y �� �
!J
❑ CONTRACT
❑EXTRA
(X!Ci�C
Out of Area Fee
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
00 Q
Gallons
O C3 v
Pumping Fee per 1000 gal.
. �'
���
cjo
0 00
Dumping Fee per 1000 gal. a
��
IOC
Out of Area Fee
�l
Locating / Opening Fee (per hour)
Size System: +
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
r
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR - AMOUNT
TOTAL
MATERIALS
-
MECHANICS Q
HELPERS Q
TOTAL
LABOR,
-,l hereby acknowledge the satisfactory
completion of the above described work:
TOTAL LABOR
TAX
SIGNATURE
'DATE COMPLETED
( V/ G
TOTAL
p0