0012-209 (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
61"563. ,AF ' dA+ 3 j VCi{aZ
114 Signature of Contractor s 71(l t
OWNER -BUILDER DECLARAZION
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.
(�w) / I have and will maintain' workers' compensation insurance, as required by
Sectlbn 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.
STATE VOND
(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 th'a`t if`I should become
subject to the workers', compensation provisions of Section 3700 of-the%Labor
Code, I shall forthwith comply with` hose provisions a!
� arte:11 ['1. L� 41--a Applicant (� r�'�/ �,> e�y_1: 7.
Warning: Failure to secure Workers' Corr, P9sation 7coverage is.unl,awful and
shall subject ani employer to criminal penaltie's.and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to . the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose, request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes. null and void:if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject' permit to cancellation.
I certify that l have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
th above-mentioned property for inspection purpfoses/%
��1
j Signature '(Owner/Agent) - x= ..f��_ •{!'° =Date r,
BUILDING PERMIT PERMIT 1i
DATE VALUATION LOT 0_ 12,-:?A�9 TRACT
UMOAV
JOB SITE
APN
ADDRESS .51-710 Ai .a 1..DA XA
773-I214*7
OWNER
CONTRACTOR / DESIGNER / ENGINEER
b5t. AIM MIRR ia1H.L ANCKTR
1:06BOER I+ROME. .iNG C ONS'.
:i 1-'710 AVERMA V=
68-1.75 BF.PMOS CO`I)I T
1-4 Qumu CA 5+225
CAXHMW, C.=Y C;.A. 92231
(760)32 7. 200 cWt 35,2 i .
USE.OF PERMIT
i •
1%LTL12iQF3DYG
SEPTI`: f'3fi.A3bi1 ON- SMA COtvNfad,.`t'. 1.,f7ifd-.MQD PROJECT' 2000-11.
VALLtATION !,$Ap,DR is
'
4
PLUiMO NG FEE —SEWER 101 000-419-000
KYt3-'7~'MAL COIATtl<i.UMON ANDPLAN C-rffIf-%
$10.00
LESIS PM, -PAID IMS
$(X00
RECEIPT
DATE �tlt '
BY..., ,
DATEFINALED
INSPECTOR
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
0. 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 aZ . D l S.T
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
CATHEDRAL CITY, CALIFORNIA 92235-2448
team 2an_7AAQ
(760)321-7448
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE ORDERED
..
ORDER TAKEN BY
DATE PROMISED ❑ A.M.
❑ P.M.
BILL TO `
PHONE
ADDRESS
Pumping Fee per 1000 gal.
MEC IC `
C1 -
CITY
r
HELPER
�LOCATION
JOB NAME AND
l F 0 IJ r
(
fvt..
p�Y WORK
DESCRIPTION OF WORK
Dumping Fee per 1000 gal.
CIO
CONTRACT
❑ EXTRA
cc,
f
i
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
6o®
Gallons
0.0o
Pumping Fee per 1000 gal.
r
f6 d
Dumping Fee per 1000 gal.
CIO
cc,
f
Out of Area Fee
Locating / Opening Fee (peer hour)
V
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 TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE
DATE COMPLETED
�"
TOTAL