0307-392 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commis ncing'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:
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).
() I am exempt under Section B&P.C. for this reason
Date gl •til.'" Signature of Owner V ;/✓�
✓ 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.
L (This section need not be completed if the permit valuation is for $100.00 or less).
.J (t,)' 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
Code, I shall forthwith comply with those provisions.
;
Date
ate: Applicant /7 %. - .
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 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. y;
•Signature (Owner/Agent)Date
y�}��•—[" — •l
"a BUILDINGPERMIT PERMIT#
O"X17-392
DATE � VALUATION$2� � LOT TRACT
JOB SITE
ADDRESS 524V7 AKEMA N" +.J0
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
LO A1�Rla'.A[M
sJV3TdF,3Z. • BMDER '
52-301AM31 A VNLLi..J'O
LA, QU TTA CA 92251
USE OF PERMIT
SEPTIC ll,BANDONE ENT, S9VMX CONNECT
VALUATION 1,590.00 LZ
EtsMATM COST OF CONS•'T"I"tfiMON
� 15A.dTi71
PERMT ]W E SUMK4RY
PLt;MB1140 FFZ-- SEWER 101-000-419-000 $30.09
80"R -TOTAL COMTRi1c": i, ON.AND P1M 0*=
$30.00
IMS FRR-PPM PM8
TUTAL PMWV' FMS DUE I9Ow
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RECEIPT
DATE
BY
DATE FIN D L
INSPECTO
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans .
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
3WYAC
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lovi Voltage Wiring
Fbdures
Main Service
Sub Panels''
Exterior Receptacles
G.F:I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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 a 3
Encapsulation
Gas Piping
Gas Test
3WYAC
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lovi Voltage Wiring
Fbdures
Main Service
Sub Panels''
Exterior Receptacles
G.F:I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Jul -31-2003 12:22pm From -PALM DESERT PUBLIC WORKS DEPT 7603411098 T-597 P.001/001 F-062
Deliver To:
Agency:
73-510 FRED WAR1NG DRIVE
PALM DESERT, CALIFORNIA 82260-2578
TELe 760 346To6>i :.
FAX: 760 341,7098
info®palm-dcrcrt.arg
FAX TRANSMITTAL
C_
Fax Number: "7 '7 r7 _70 I) Date: _V3)/03
Verify: 1 PAGES INCLUDING THIS COVER SHEET. IF THIS TRANSMISSION IS
INCOMPLETE, IMMEDIATELY CALL PERSON DESIGNATE.) BELOW:
From: nl Grua 6 L~ tz2� r►"S"
Department: Phone: • G44-7 i �
Comments:
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LORENA ERRANTE
ABCADVERT14SiNG
52-907 AVItNIDA VALLEJO'
LA QUINTA; CA4 92253
Yt ,
TELEPHONE (760) 777-7012 FAX (760) 777-7011
-
OWNER/BUILDER INFORMATION
Dear Property Owner.
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by properly owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law;to be licensed and bonded by the State of California and to have a business license
from the City or'County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or "more for the entire'- project, and such .persons are not licensed as contractors or
r' suhcontractors, then you may bean employer.
If you are an employer, you must register with the State and Feder3il !Government as.an employer and you are subject
oto several,obligations,including,State and,Federal income tax withholding, federal social security taxes, worker's
compensation insurance; disability insurance cosis and unemployment-compensationon contributions:
There may. be financial risks for you if you do not carryout these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. `
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their ,
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the property owner is providing his or her own labor.and material personally.
Building permits 'are not required to be signed by property owners unless they are performing "their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board iii your
community or at 1020 N. Street, Sacramento; California 95814. •, -1
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of '
these matters. The building permit will not be issued until the verification is returned.
Very truly yours, ` !
r
CITY OF ILA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7012 ,
FAX: (760) 777-701 '
off- 0. �3 . • •
OWNER 'SeS NA RE/DATE
1A
PROPERTY ADDRESS
0107-39-Q
PERMIT NUMBER(s)
r � .
2
a
HAMMER PUMPING INC.' ,
P.O. Box 2448' -
CATHEDRAL CO, CALIFORNIA 92235.-2448
(760) 360-7&48
—JOB�INa/O10E-•
(760)321-7448-- .
CUSTOMER'S ORDER NO.
DATE ORDERED
30 '0 3
ORDER TAKEN BY
DATE PROMISED - , ❑ A.M.
. P.M.
BILL TO --� , ^Y -
PHONE
ADDRESS _
//MMECHANIC r•�
CITY f� _ -- i
HELPER -`
JOB NAME AND LOCATION-
�,❑
t
DA .WORK
DESCRIPTION OF WORK ��jJ//- //,� / - ••., -
O{ 1 V V C I f/ c .� O (`� �y"i .•
- [D CONTRACT
1:3 EXTRA 1
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
O
Gallons
r
Pumping Fee per 1000 gal° , r
/OU.
(U,G
c
OO
Dumping Fee per'1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
\
Size System:
'
C 76,3 s
-
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
MECHANICS Q
HELPERS Q
TOTAL
LABOR
I hereby acknowledge the satisfactory
completion of the above described work:
TOTAL LABOR
TAX
SIGNAjj -
yt�
- DATE COMPLETED
TOTAL