0012-207 (PLBG)�` LICENSED CONTRACTOR DECLARATION,
"I hereby affirm under penalty of perjury that I am licensed unifier 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. Cllacs^s � Exp - Date
AD Hj
Date Signature of Contracto
�t OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt.from the Contractor's
License Law for the following reason:,
( ) 1, 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.0 for`this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby`.affirm under .penalty'of perjury orie 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.
STATE FUND i3�4-�•1�019�7q
(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
sulct to the workers' compensation pr'ovisions-of Section 3700 of;the Labor
Code, I shall forthwith comply with those provisions, /f
Date: / f d %� t :0 Applicant X 4� t�
.i
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 -be ' comes null and void if
work is not commenced within 180 days from datof 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. 1. agree to comply with all. City, and State laws .relating to the building
construction, and hereby authorize representatives of/fhis City to enter upon
the
bove-mentioned property for inspection purposes ,
r �r
Signature (Owner/Age'nt) Date ' ! l`
BUILDING PERMIT PERMIT"
DATE VALUATION LOTiTRACT
�C1,�Oib.ItSf _
JOB SITE
APN
ADDRESS MM CALLE Se.d"tALOA
OWNER
CONTRACTOR / DESIGNER / ENGINEER
rifiwat"9}Lm wC reaRwo cC9wsr.
17.395 Cl�.i�:;�ZritAOA
685 MhID6 �'C���
LA. QUIWA CA 92.253
i KMMIRA , WY G'A. 52234
C760),41" I-2200. " 3-77
USE OF PERMIT
�0*1hC 'SE"'W2R. C:0NN1?.4,T, I.C?Wd MOD PROJECT 2006-21.
VALUATION
E�r�i..i.'P+t�. = 4 ii4 4.DF CC3m6i 1J 'tori
! 1M!
PMfT 11W 90MAIARY
PLUMBING FU,- SZWZ d. l Cal -000.4 ].9.000
SUB-Tcr AL CONM(MION ANI) KAN CMCK
530.00
UISO M-PAMM-3
$0,00
- T0rr.Ey.®J..4 hX. ME,S.a.r17n Df./.lSa:t.Y"W'9'J
�TWr
RECEIPT
DATE i
BY•
DATE 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 & 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 I
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
• BS7
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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 0. Box 2448
CATHEDRAL CITI, CALIFORNIA 92235-2448
17FAI gan_7AAq
1 r
(760) 321- 7448
PRICE
AMOUNT
CUSTOMER'S ORDER NO.
DATE ORDS D
�-
Pumping Fee per 1000 gal. j!r�
-a- a""
ORDER TAKEN BY
DATE PROMISED ❑ A.M
umpin; Fee per 1000 gal.
o
I] P.M
BILL TO
PHONE
ADDRESS /r
MECHANS1
CITY
HELPER
JOB NAME AND LOCATDN
w..
S
<' �•
❑DAY WORK
DESCRIPTION OF WORK
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
❑CONTRACT
❑ EXTRA
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS LABOR AMOUNT
TOTAL
MATERIALS
MECHA141CS @
HELPEFS @
TOTAL
LABOR
QUANT. DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal. j!r�
umpin; Fee per 1000 gal.
o
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
MECHA141CS @
HELPEFS @
TOTAL
LABOR
I hereby acknowledgethe fisfa ory
completion of the above •g�scribe ork:
TOTAL LABOR
TAX
SIGH. ATURE
Jr
DATE COMPLETED
TOTAL,C�