0110-211 (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 *'f
684 563 ADR"i
rX'4L r SIPA.1
Date f 7 2_10( Signature of Contraltorr ` Z2,
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 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.
,(mol have'a`nd 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 �IyA?g E UND Policy No. AJA,,-03.-09IV224
(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 subjectld' the
workers' compensation laws of Califo'rriia,; and agree that iVl should ecome
subject to the workers' compensa It on provisions of'SSection 317000+of a Labor
Code,.l s9 ll..forthwith comply/with those rovisionsh
Dater/ _l.� r Applicant A" ��T
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}autfiorike repres'e`ntaflves of,thisACity to enter upon
the above-mentioned p,opgrty for inspection purpb ses
Signature (Owner/Agentij7. 'y'k /�%lv' • •�i'� "hate
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BUILDING PERMIT PERMIT#
DATE VALUATION LOT 01,10-241 TRACT
JOB SITE
APN
ADDRESS � � AMA
7?0 (.%_ 6 L1►
OWNER !
CONTRACTOR/DESIGNER/EN INFER
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LAQU:UI'L CA, 922-S3
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USE OF PERMIT
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NOV 2 8 2001
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SM -TOTAL C;ON�'T,r� UC:TIC?N ) PLAR C:IMCK
$30.00
.7,1K!']1,L3.R;t
RECEIPT
DAIE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footinds
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 8 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_
Sewer Connection
__
�- O-2
Pool Cover
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 (Perm)
_ HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448 ;w
CATHEDRAL CITY, CALIFORNIA 92235-2448
17ani 2an_7AAQ
(760) 321-7448
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
Dl OR D ^j_
Gallons
a,`fj l/
ORDER TAKEN BY
DATE PROMISED 0 A.M.
Pumping Fee per 1000 gal.
51
"t—�-
0 P.M.
BILL TO
PHONE
y _S �r
I �
�
ADDRESS
MECHANI�S' f
I/
CITY
HELPER
JOB NAME AND LOCATION
Out of Area Fee
1 `
0 DAY WORK
L
DESCRIPTION OF WORK
Locating / Opening Fee (per hour)
0 CONTRACT
0 EXTRA
11
r-vc- r
O
Size System:
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
51
"t—�-
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 Q
HELPERS @
TOTAL
LABOR
L Ilk t
I hereby ackh4wledge the suis ctory
completion df the above de cri d work:
TONAL LABOR
TAX
SIGNATIJR€
'�� `\► V\ r �.
DATE COMPLETED
2
TOTAL
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