0311-134 (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
476543 Cla o8/31.12(
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).
( ) 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 ,,rAi.T I7i.T,�ND Policy No. Cs/46•$2 91x9$bZS
(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 scomply with those 7provvisiions.�*
Date:Applicant
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 property for inspection purposes.
Signature (Owner/Agent) ��• %'- ` � -It Date ,
BUILDING PERMIT 1 PERMIT#
DATE �` °�/� VALUATION �i-gr p� LO TRACT
JOB SITE
ADDRESS M-691 AV N .��+ 111ILLA
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WGUE, ROM
COG'"fRF' N f.20N d!tlUN CATTON COTS" RUX1`%"
52-091 AMACAVULA6-630
CAT
LA QMYEA CA. 92253
C:AAEI. RAL C,C' f1i . CA_ 9 234
(760)32.13-67118 Midi € 65
USE OF PERMIT
SEPTIC. AHAN00NZM1,?NT-3FWETC C01MIXT.2001 CBC.
VALUATION 113a .,,.
NS".UM.�.` 0131 0093.1 OF C101T. TrRUCTCUH
� N3CiYJ.i3iB
PLUMSMIG PEE SEWER 101 -000-419-000 MAID
D P
D APLAN,, t� ,Y
IN -S-9 PRET-PSD M0111
$0.00
NOV 17 1003 4q x.nKW1,UsYt_1"r DIN NOW,
Moo
CITY OF I A QUINTA
FINAeYC E�DEPT.
RECEIPT
DATE
17, .
BY /�
DATE �INALOED /,�
INSP C
` l
INSPECTION RECORD
OPERATION j
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
All
Final
COMMENTS:
Utility Notice (Gas) fl
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)
WFF
HAMMER PUMPING INC.
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
17C/A1 OCA 7AAO
�_.JOB-'INVOICE.
QUANT.
(760i321-7448
PRICE -!-AMOUNT
CUSTOMER'S -ORDER NO.
DATE ORDERED
�� ®G
ORDER TAKEN BY -
DATE PROMISED A.M.
O O
*
❑ P.M.
BILL TO
PHONE
ADDRESS
-
HANIC
CITY
--^•
HELPER
OB NAME�yAND LOCATION
,V //C v �l �C w
��
❑ DAY WORK
DESCRIPTION OF WORCK,�y `/%
G/X/l/O '! �V ...]'
:✓✓ t
❑ CONTRACT
❑ EXTRA
Locating / Opening4ee (per hour)
QUANT.
DESCRIPTION. OF MATERIAL USED
PRICE -!-AMOUNT
Do
Gallons
O O
Pumping Fee per 1000 gal.
O G
Dumping FeeTper 1000 gal.
Out of Are j ee--;"
Locating / Opening4ee (per hour)
ti
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 , Qa
!I
HELPERS _ Jj� Q.
TOTAL
LABOR
5
V reby acknowledge tUhte satisfactory
completion of thelaboJe descrf)bed work:
TOTAL LABOR
TAX
SIGNATURE / J /
DATE COMPLETED
TOTAL
WIN
a
Remarks:
r
p,Copy to: 1 +
y
COACHELLA VALLEY WATER DISTRICT -
9,3797
i/
1
3
CASH RECEIPT DETAIL
J1 %
E
�
Water Service
- !
r •i `: j i' �.j�
! i
Date:
.
Received From:
Address: r r v to �s
(1
14L Tract
Ny >..
Account No. fir= % y9
Lot(s)
-Service Address ' < < I ('
' G.A. Code.
,
❑ Meter(s) ,
$
,
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ " Detector Checks) -
)"❑
`
0Meter,Surcharge
r
Samfation.Capacity Charge
-
0 W.S.B.F.Cr
❑ Temporary Construction Meter
❑ "Turn on Charge
O Uncollected Account - Name"
❑- Inspection Fee -Tract -
Fee -
;.
❑ Plan Check Fees Water) Sewer -
Tract -
r d ❑ Bond Payment - A.D. - Bon
•
j -
Assmt.
❑ Customer Deposit
i
❑ Other
-
TOTAL
Remarks:
r
p,Copy to: 1 +
i/
1
t
�
Water Service
Ea
eCashier
`
Ny >..
CVWD-<.
,