9511-065 (PLBG)N
LICENSED CONTRACTOR DECLARATION I - .. Qy1LU11141
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing With DATE . 127 519T VALUATION ZDI., 1A-'*.tM LOT
Section 7000) of Division 3 of the Business and Professionals Code, and my
License is in full force and effect. 684563 A 1129/96 55B SITE ADDRESS 51-095 AVENIDA .BALL EJO
License # LIC. Class— ---% Exp. Date r I -OWNER CONTRACTOR
Date j, -,..j SSig nature of Contractor 40, L_ 4_1 I. Al
DENBOER ENGIN1130"RIVO &CONST.
OWNER -BUILDER DECLARAI(ph MS. UNIDA ROTHSrErN 68175 BE RROS COURT
I hereby affirm that I am exempt from the': Contractor's License Law for the .51095 AVENIDA VALLEJO CATHEDRAL CM` CA 92234
following reason: LA QU[NTA CA 97.243 (619)327w=0 CI L# 351n
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 DESIGNER/ENGINEER
sale (Sec..7044, Business & Professionals Code). USE OF PERNPLUM01NIG
1, as- owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 1044, Business & Professionals Code).
( ) I am exempt under Section B&P.C. for this reason SEWER CONNIECT
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION FEE DESCRIPTION
I hereby affirm under penalty of perjury one of the following declarations: CONIRACT AMOM 11724.00 LS
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 'qCarr 14MM Policy No.
110A44n ESTIMATED COST OF CONSTRUCTION
(This section need not be completed if the permit valuation is for $100.00 or less). PERMIT FEE SUMMARY
I certify that in the Performance of the work for which this permit is issued, PLUMBING FF -E "" SEWFR 101-00.0-419-000 $X00
I
I S" not employ any person n any manner so as to become ...J—
+ 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
Code, I shall forthwith comply with those provisions.
Date: 1:2 J:?JaApplicant - 4
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,aliplication is made & each person at
whose reqijest and for whose benefit work is,performed under or pursuant to
any permit issued as a result of this application agrees to, &.shall, indemnify
,,,.& hold harmless the City of 6_41. WIts officers,. -agents and employees.
1 2. Any permit issued as a result of this application becomes null and void if
ww'
ork 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.
.1 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 Cd'
y to enter upon the
above-mentioned property, for inspection purg6se6�
,6S_S1,
-Date
Signature (Owner/Agek)W 04�11 ae e,_,_
, 0 / RECEIPT
-7
I PERMIT
I TAW'tT
773-062-024
SUB-110TAL CONSIRUC110N AND PLAN CHECK
LESS PRE -PAIL? FEES
TOTAL PERMIT FEF-% DUE NOW
DATE BY DATE FINJ
2,724.00
*30.00
$0.00
530.00
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
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
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:
/I
AMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
Ir -11101 2CA_7AA0
1-1 - - iw
(619) 321-7448
CUSTOMER'S ORDER NO.
DATE ORDERED
j -A 13 - � C
10 O Gallons
ORDER TAKEN BY
DATE PROMISED 0 A.M.
Do O Pumping Fee per 1000 gal.
0 P.M.
BILL TO 3,
PHONE
ADDRESS
MECICtt
(✓ Cw.0
CITY
HELPER
)B NA LOCATION
`
%
0"DAY WORK
'jr/ t4 ' 1i L
CRIPTION OF WORK
0 CONTRACT
0 EXTRA
Locating / Opening Fee (per hour)
,UANT. DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
10 O Gallons
Do O Pumping Fee per 1000 gal.
Q Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR
WILL BE CHARGED ON PAST DUE ACCOUNTS 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
'4;w
DATE COMPLETED
AJ 7(o
TOTAL
1 _
H(MC E Vo OTMn
Under the California Mechanics Lien Law any contractor, subcontractor, labor`S'Upplier
or other person who helps to improve your property, but is not paid for his/her work or
supplies, has a rignt to enforce a claim against your property. This means that after a court
hearing, your property could be sold by a court officer and the proceeds of the sale used fo
satisfy the indebteJness. This can happen even if you have paid your contractor in full if the
subcontractors, laborers or suppliers remain unpaid.
To preserve their right to file a claim or lien against your property, certain claimant -s such
as subcontractors or material suppliers are required to provide::you with a docufnententitled
"Preliminary Notice." Original (or prime) contractors and IaborerN ,entages'do not.lhave to
provide this notice. A Preliminary Notice is not a lien against y60r Its purpdsie is to
notify you of persons who may have a right to file a lien against your property if #flee are not
paid. Generally, the maximum time allowed for filing a claim or lien against your property is
ninety (90) Days after'completion of your project.
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY,
YOU MAY WISH TO TAKE ONE OR MORE OF THE FOLLOWING STEPS:
J�
1) Require that payments be made directly to subcontractors and material suppliers through
a joint control. Any joint control agreement should include the addendum approved by the
Registrar of Contractors.
2) Issue joint checks for payment, made out to both your contractor and subcontractors. or
material suppliers involved in the project. This will help to insure that all persons due payment
are actually paid.
3) After UPON making payment on any completed phase of the project, and before making
any further payments, require your contractor to provide you with unconditional lien releases
signed by each material supplier, subcontractor and laborer involved in that portion of the
work for which payment was made. On projects involving improvements to a single family
residence or a duplex owned by individuals, the persons signing these releases lose the right
to file a claim against your property. In other types of construction this protection may still be
important, but may not be as complete. TO PROTECT. YOURSELF UNDER THIS OPTION YOU
MUST BE CERTAIN THAT ALL MATERIAL SUPPLIERS, SUBCONTRACTORS OR LABORERS
HAVE SIGNED.
J,-
TRI=STAR CONSTRUCTION
P.O. BOX 542
CATHEDRAL CITY, CA. 92235
ph. (61.9)-
fax.
6].9) fax. (619) 321-7798
TO; CITY OF LA QUINTA
RE:.vl-;7��
PER MY AGREEMENT WITH TRI -STAR CONSTRUCTION I WILL.RE-SEED OR
OTHERWISE COMPLETE'MY YARD AFTER THE INSTALLATION OF THE SEWER.
THANK 'YOU ,
signature
please p�-'iiit ,name