0302-199 (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
80.3145 C36 H:IC In 1A -4C
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).
O ,I am exempt under Section , B&P.C. for this reason er
Aate , '� � ��`^ c°.� _ Signature of Owner
WORKER'S
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 tymeArrg FUND.: Policy No., 1,105218
(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 sh ll 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 Se�tiom3700,„of the Labor
Code, I shall forthwith comply with those provisio s. / t
d
Date: �='- mph �c`_j Applicant—
Warning:
pplicant
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/ofthis City to enter upon
the above-mentioned property for inspection po�ur//poses: fff�
Signature (Owner/Agent) r �"�`, 7” %'�'`I Date
-' BUILDING- PERMIT PERMIT#
DATE �ry•yyy qq���� p����ryp((•• VALUATION �C4. ,¢��7�q/y LOT `�� TRACT
6laG/NLNR OC ".0, 4A14Jf. AX)
JOB SITE APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / EN (NEER
ZA
SA.QtYWfA -A. 9225: SAT1,13liK:Z IRO:.:,. CA, 92410
(160)327,x1583 clwfll
USE OF PERMIT
PURVO-Wo
SEMER AiPA.WDO'XEMMT '
V.r LIJAVOIN
40101 DO L3
k'EM011,91RE IRMIKARY
PLUMa ;1140 FEE -- 8MER 101.OW-419-000 $30,00
SUB-TO?AL CC).i�O' FLI'M0M.l ND K" QWXK
Q
125.9 P,I$.UHP FRES
D
FEB 2 8 1003
CITY OF L & Q_UT,EgTA
RECEIPT I DATE / __ / I BY
INSPECTOR
$30,00
$t?.UD
$39).0+
tl
.. ._.. .A
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 a _ _ _ _ _
t. Sewer Connection .3 ��
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
_
T/a vG� iz '3
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)
FA
HAMMER PUMPING INC.( - JOB INVOICE
`. 'P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
7&^ .'3&n 7AA0-.I
QUANT. DESCRIPTION OF MATERIAL USED
�
CUSTOMER'S ORDER NO.
D�ORQ� D
(760)321-7448''
I
d
ORDER TAKEN BY
DATE PROMISED 0 A.M.
'
.
0 P.M.
BILL TO
PHONE
ADDRESS -
�.' �``
MECHANIC
CITY
HELPER
JOB NAMEAIVD*LOCATION ` I
�r (/
Locating / Opening Fee (per hour)
❑DAY WORK
~J to
DESCRIPTION OF WORK
0 CONTRACT
0 EXTRA
i Q r.
S E' G✓ Cid' ��V i/lF�� _�/
QUANT. DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
f'Soo Gallons
Pumping Fee per 1000 gal. I
o
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.
18% PER YEAR WILL BE CHARGED ON
PAST DUE ACCOUNTS OVER -30 -DAYS.
HOURS LABOR .,AMOUNT
TOTAL
MATERIALS
MECHANICS ®
HELPERS ®
TOTAL
LABOR .
I hereby acknowledge the satisfactory
completion,orthe above described work:
TOTAL LABOR
TAX
SIGNATURE
.�..�'
DATE COMPLETED
TOTAL)
a
HAMMER PUMPINGINC. JOB INVOICE
P.O. Box 2448
CATHEDRAL -CITY, CALIFORNIA 92235-24
17CA1 4C/1 7AA4
(760)321-7448
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
D ORDERED
j
r®6 (D
/
ORDER TAKEN BY
DATE PROMISED ❑ A.M.
r ov
Pumping Fee per 1000 gal.
❑ P.M.
BILL TOP��q//�
_
S
PHONE
ADDRESS
ME'(iHANIC
7y ."
CITY ,.
IJ—0
HELPER
JOB- A E ND LOCATION �'
7 _
DAY WORK
Out of Area Fee
DESCRIPTION OF WORK
®
❑ CONTRACT
❑EXTRA
Locating / Opening Fee (per hour)
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
r®6 (D
Gallons
r ov
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal. l
IJ—0
m
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
MECHANICS Q
HELPERS @
TOTAL
LABOR
I hereby:.acknowledge the satisfactory
completion of the above described work:
TOTAL LABOR
TAX
SIgNATURE
`,
DATE COMPLETED
r`
TOTAL
Y'
COACHELLA VALLEY WATER DISTRICT.
CASH RECEIPT DETAIL 9 93868
Received From: + 4 .. Vii'/ (.: i �� s •l
Date: 1 . `% I " . •. j
I_
Address: Lr- l/(; 7 .�C.�%. tI✓.�.�/ �7 4-A
Account No. (rri ;`�r�-M-�•,..:�.�� , a r Lot(s) Tract
Service Address "I - �'/ .� . 'tt�t ,' / . / !•-'j c'.1 L_, '
G.A. Code
i. i
❑ Meter(s)
$
❑ Service(s)
! ❑ Backflow(s) I
❑ House Laterals) i
❑ Detector Check(s)
❑ Meter Surcharge
• ;lQ• Sanitation Capacity Charge waw• `� = ,�,
❑ W.S. B. F.C. I
❑ Temporary Construction Meter
❑ Turn on Charge
❑ Uncollected Account - Name -
❑ Inspection Fee -Tract -
Fee -
(
❑ Plan Check Fees Water I Sewer - 'J
• if ''� '
Tract -
i ❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
1 ' TOTAL $ % �% .� .. ►
Remarks: 1 !
1. .
I
!1❑copy 10:,.Vt-
Cash i; ;, ft Water Service
Check '; ! ;:` ✓:
~
Money ;,✓
Cashier.,' y'
Order "' j 9 ..-,r.° CVWD-438 (11189)
3