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0210-160 (PLBG)LICENSED CONTRACTOR DECLARATION I .hereby affirm under penalty of perjury that I am licensed under 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. Class Exp. Date 475$1:5 .,kFix �j r � 461B0/V Date''AO >" 6 Signature of Contractor'—��/ •�{'� 7 . OWN ER-BUILDER'DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's r; 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 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 STATE FUND Policy No. 044.02-091"98 (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 tote wor ers' compensation pr,9ftiions7off Section 3700 of the Labor Code ,}y sh I forhh comply with«'t�hSsL e•p "ovsio ii "�, ,, , jDaApplicantt Warning: Failure to secure`- orkers' 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 hi°s 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, indem ' & hold harmless the City of La Quinta, its officers, agents and employe n 2. Any permit issued as a result of this application becomes.null and voi �J work is not commenced within 180 days from date of issuance of s" permit, or cessation of. work for 180 days will subject permit to cancellati I certify that I have read this application and state that the above information's correct. I agree to comply with all City, and State laws relating to the buildi g Construction, and hereby authorize representatives of this City to enter up the above-mentioned property for«�i spection purposes. _ X Signature (Owner/Agen't' � Date °, BUILDING PERMIT PERMITN 0210-460 DATE VALUATION $JY SX0a00 LOT TRACTJOB SITE . ADDRESS j 5$,,,F G AVE. VKUJUO APN 77 ..?A -002 OWNER MR. C311LB M-TPia C1E 54 °280 AV•.�, VX L.E0 a Q TLiV A USE OF PERMIT PLUNMM40 CONTRACTOR/DESIGNER/EN (NEER TPJ, SEAR Ca3NS1MT610.9 CA 922$3 (!XrWdDRALCTCY CA 92,235 (760)321.0898 CB1.4 762 SE,PT1C,R8A04D0N, SE'9d`SP, HOOK-UP Vd43,sl)ATION ] TtM,TM) COST O W148MBSC T11:01i 2 .4 PFJOAIT M &VMMA vY PLUMDr to Fn 101 -WO -419-000 $30.00 41 90BAVfAL i"t T Idk?L"FSON AM'Pa. A -K CI-EXX. S 310.00 F �1 'Rf Alla P� $0.00 LK OCT 2.t2062 CITY OF LAQUINTA FINANCE DEPT. RECEIPT DATE jj ABY , , 1 :[DA E FINALED L INSPEC OR 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 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 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 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 (Penn) HAMMER PUMPING INC. JOB INVOICE P.O. Box 2448 CATHEDRAL CITY, CALIFORNIA 92235-2448 17an1 Zan_ 7AAQ (760)321-7448 QUAINT. DESCRIPTION OF MATERIAL USED CUSTOMER'S ORDER NO. DAT 0 DERED �5 - , ORDER TAKEN BY DATE PROMISED 0 A.M. 0 P.M. BILL TO PHONE ADDRESS Dumping Fee per 1000 gal. MEC IC CITY - HELPER Y� F i Out of Area Fee JOB ME _�Y WORK 0 CONTRACT 0 EXTRA I DESCR_PTTIION OF WORK (\� �G �.V�Cp � 17C - QUANT. DESCRIPTION OF MATERIAL USED PRICE AMOUNT © o Gallons Pumping Fee per 1000 gal. 1 J Dumping Fee per 1000 gal. Out of Area Fee Locating / Opening eeJ}e (per hour) /F 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 MECHANICS HELPERS @ TOTAL BOR 0 I hereby acknowledge the satisfactory completion of the above described work: TOTAL LABOR TAX SIGNATURE DATE COMPLETED `` '�' TOTAL �