0309-254 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions o
Chapter 9 (commencing with Section 7000) of Division 3 of the Business an(
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
4WZ180 C21 C4 11/30/211
,Da"te Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor';
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 fo
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with license(
contractors to construct the project (Sec. 7044, Business & Professional;
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 COMBR4ED SPECML Policy No. 00.00011613
(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 the Labol
Code, I shall forthwith comply with those provisions. l rwN
Date f..a n.L-2 Applicant,fi�� .
Warning: Failure to secure Workers' Compensation coverage is unlawful anc
shall subject an employer to criminal penalties and civil fines up to $100,000, it
addition to the cost of compensation, damages as provided for in Section 370E
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 ai
whose request and for whose benefit work is performed under or pursuant tc
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 H
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 inspeccttionn purposes.,
Signature (Owner/Agent'\I_."'"�-%7`��� raj - Date --��
/
BUILMNUP.��ERMIT PERMIT# �
�>
DATE VALUATION � LOT TRACT
JOB SITE APN
ADDRESS 53-M AVNNIDA `id7+MASCO
OWNER CONTRACTOR/DESIGNER/EN &NEER
PA1'J1',AV€ TJGHfiN ALMS UND} RTP.OUN Ct NTf.
53-898 AVFIWA'�'M ASCO 3€11703 VIffAI>:Et:CVF
I A QUIN A. CA 92233 C6, 1'FWZRAL l Tff C % 92234
(76Q)324-1911 tM- 14 769
USE OF PERMIT
PI UMBlNG
SEPTIC A;B.AN'D0N;'SZMR CONNECT
V'.4WATION
$1500.00 LS
Wrp"1= OST 0, CdJNSTRUCI7O14 �,S?Si,Qfl
COSTPKEWCF SUMMARY
101-000-419-IOMINO Y42: •. SWER 101.000.419•M $4,D 1
D QXJBwi rAL CC I rRUCT1014 AND PLAN CHECK $30.00
SFP 2 2 2003 r _• a PERK= :VZ:S DUE NOW Amo
CITY OF LA QUINTA
FINANCE DEPT
RECEIPT DATE BY , DAT FINALED INSPECTOR
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 8 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
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
-�jo Sz
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)
-Number cif pa esaincludn�,
JM.a,4„cn+ .. ,: ..i..+ ".r+ ,,l•+ti .o`K�Y�....+ +-.A..... , ^-` �, t ""• iFyr�l' f'R' - 7. .<"j ,
• r r ,r r --------------------------------------
------------------------
- ;,�•-
--•-- - - -- _ - - -- - ---,760 778 '03�1'`�r T-864 P 002/002 F-025
sap -1 10 53am From—Kinko- - -"�-
DIS
TRRCT
COACMELI:A VAI.hEY WAT ( '
' �
,
- ��ww'�llJJ
,..
.: ,
co
f Aopoy It N�„
;r' ~:Borv�ee'A'd r a G;A.'Coda
_ _
:,�1"Seryat
TIC e,j
,
'r:r-.,:••.p:rhleuse,L"atatal(s)•....:
.. ,....
( —
G '
-:DAtactor:Check(s)- - -�.�. _ •'�
Fi :• a. IFptlo 'CQpa6IW Chaf9e' �-- . � ' � • L `( ;1
i; :... �1.... ,�. -
�1
,
�,-UF �.-1"
4
Tract -_ - =
o},•�. .CustoV,��er.D� yoalt �.-- - .r J-�
TOTAL
77
IT
Water. Go
JCa
1
GAO
n:
-
'�l��
1.•,
Order .� .s:. i3y `!;'i'. cVwp-4aad?1r✓3g�'.
-
,.. .,-� ,.: ��• ....\.: ... ,. ,: :";': .. r..,-•,-" - �, ,, n.� � '�'l �":�f�.,� .���t• i' yin �. nr�,i•1 �i' � i,-.'�i n� '•i'�a" �i � �o' I' n�•,.
FROM HAMMER PUMPING INC FAX NO. :'7603433025 Sep. 23 2003 12:19AM P2
iiviw% rwiviriivu iivto., JUD
r-- �. :'•;\ ►to�..�,,__� P.0, Box 2448
321 7448
0 P.M.
BILI TO
PHONE
CITY
HELPER
JO N
YWORX
:Y
EXTRA
r.
Gallons
O41
Pumping Fee'per 1000 gal.
5—
630
Dumping Fee. Der 1000 gal. _J'o C,
C _3 r—
Out -of Area Fee
Locating Opening Fee.(per hour)
Size system:
ASERVICE CHARGE OF $20 WILL BE DUE
-ON ALL RETURNEWCHECKS.
321 7448
0 P.M.
BILI TO
PHONE
CITY
HELPER
JO N
YWORX
:Y
EXTRA
DESCRIPTION OF WOR
Gallons
O41
Pumping Fee'per 1000 gal.
5—
630
Dumping Fee. Der 1000 gal. _J'o C,
C _3 r—
Out -of Area Fee
Locating Opening Fee.(per hour)
Size system:
ASERVICE CHARGE OF $20 WILL BE DUE
-ON ALL RETURNEWCHECKS.
18% PER YEAR WILL BE CHARGED ON
PAST -DUE ACCOUNTS OVER 30 DAYS.
• HOURS
LABOR. -AMOTN-T'
TOTAL
MECHANICS MATERIALS
TOT
HELPERS @ LABORAL
lh=,arkni?ivirdgc!the satisfactory
co on of the above described W.rkt TOTAL LABOR TAX
SIGNAYURE: DATE COMPLEI E),
TOTAL.
T