0209-076 (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
Date �• ` Signature of ContractorW
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.
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:
Carner 32i 'xk Flte�l. RIfW .°� Policy No. !i'920290 -
(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 to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions . ,�-t „ ,
r4
bate: 'I ` 13,* {}'� Applicant' AtU 011 � �a,c i� , l
i
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 propterty ffor insp ction.purposes.
Signature (Owner/Agent) ` ''-- w--- - -- ` Date
BUILDING PBRMI PERMIT#
64 t
DATE VALUATION�� LOT¢ TRACT
Q I �I fJC ",20, 00 2,4 :ice, IJ"k.?SCLUL.
JOB SITE
ADDRESS 51-29-6. CAUX IRTEXCh
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
51-296 CALL'S, RUMIN ;
75M Awlff. 01AR x3.1.114 4B
: A fe3"It� 't, s
T�r�Lj :l�k4`i C CA 922. 1
(.?60)341.0557 asLif 00695
USE OF PERMIT
PLL7NQR40
SLS-PTIC A b AN DONM 9NT•5RiB W1 }-f(31:tI:C:-LYP
VALUATION, � %no,00u
FWMd&+7LE D CONT Q%' S.rL1NS,G.'�WC_ •Aryn,✓w
iJ' 1+�'�✓•'�`i -
s 3.UM01140 F rA_ -� NVE11, 101-000-419-000 Dli O
r
�p a ,� _ •
'SEP 112 0
CRY®FLAQUINTA
FINANCEDEPT.
M M.S k -I �cyrAL C:f�DI tCI�f10Y14AM3 PLAW O'BUX 4
20.00
• f ;I't"m itis nqw, mrs 3
S-0.00
RECEIPT
DATE,BY�
FINALED
INSPECTOR .
W."
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I.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 Wail 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 I
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 Z_
Pool Cover
Sewer Connection v
Encapsulation.
Gas Piping
Gas Test
Appliances
A w�/C— 6
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
kf—G.
F. 1.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
(76ni sAn.7AAR
(760) 321- 7448
'
CUSTOMER'S ORDER NO.D
E O D7ye4
ORDER TAKEN BY
DATE PROMISED Ef A.M.
O P.M.
BILL TO f f
PHONE
ADDRESS v
MECHANIe I
CITY
HELPER
JOB NAME AND LOCATION C/�,
Z'
❑DAY WORK
DESCRIPTION OF WORK `f
/. C ro }.-
O CONTRACT
❑ EXTRA
DANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
le)06
Pumping Fee per 1000 gal.
fL
Dumping Fee per 1000 gal.
S O
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 aclCFiowyTe2ge thesat s,Iactory
comphet-ac of the above describ`edlwoa,:
TOTAL LABOR
TAX
SIGNATbR,E '` _4.
DATE COMPLETED
TOTAL
/ 71
1
kr
I
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
TOTAL C/ L/
Water Service
Cashier
CVWD - 438 (11189)
fi.Uv
C, 1593
Received From,
N 1""'
k c,
0 Meter Surcharge
Address:
-_S n1tation Capacity Charge
2'a
(account No. .
L?t(s)
Service Address-
Tract,
+A
ij. G.A. Code
'*0 Meter(s)
0 Turn on Charge
0 Uncollected Account - Name
$
0 Service(s)
•
Fee -
TOTAL C/ L/
Water Service
Cashier
CVWD - 438 (11189)
0 Backflow(s)
0 House Lateral(s)
0 Detector Check(s)
0 Meter Surcharge
-_S n1tation Capacity Charge
2'a
0 W.S.B.F.C.
0 Temporary Construction Meter
0 Turn on Charge
0 Uncollected Account - Name
0 Inspection Fee - Tract -
•
Fee -
0 Plan Check Fees Water / Sewer -
Tract -
0 Bond Payment - A.D. --Bond
Assmt.
0 Customer Deposit
0 Other
Remarks:
Erdopy to:
Cash
Check
-Money
Order
TOTAL C/ L/
Water Service
Cashier
CVWD - 438 (11189)