0210-156 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that |amlicensed under provisions of
�,hapte,9(commencing with Section 7noo)o/Division 3u,the Business and
Professionals Code, and myLicense ioinfull force and effect.
License # uv.o/ma Exp. Date
473 15 A B
Date /6 ure of Contractor,
'
OWN GR'BW|LDtR1bEC LARATON
oereuyaffirm under penalty cxperjury that |omexempt from the Contractor's
License Law for the following reason: . ' _
( ) 4 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).
( ) , 1, as owner of,the property, am exclusively contracting With licensed
Contractors to construct the project (Sec. 7044, Business & Professionals
I am exempt under Section' B&P.C. for this reason
Pate Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby'affirm under penalty of perjury one of the following declarations:
(J I have and 'will maintain a certificate of consent to self -insure for workers'
dompensation, as 'provided for by Section 3700 of'the Labor Code, for the
p0ormance of the W6r'k for'which this permit is issued.
have and will maintain workers' compensation 'insurance, as '
Section 3700 of the Labor Code, for the performance of the work for which this
pe'rmit Is issued. My Workers' compensation insurance carrier & policy no. are:.
Carder OTAT91U.41) Policy No. 044412401VM
�This -section need not be completed if. thepermit valuation Is for $100.00 or less).
I certify that In the performance of , the work for which this permit Is Issu6d,
/Shall not a m loy any person In any manner so as to become subject to the
workers' compensation laws of Callfomi and agree that
subject to the workers' compensation provIsIons,of Sectlon'370b of thei Labor
Da a Applicant 4�2
Ilure to
s6 11�
a Is b ct an employer t; criminal peniltles and civil f Ines up to $1 00,000.- In
addition to the cost of compensation, damages as provided forlin Section 3706
—,_---- Code, Interest, and attorney's fees,
IMPORTANT 11 Application is hereby made to the Dir . actor of Building ani;�af4ty
f6r�' a permit subject' to the conditions and' restrictions set fol4h on Rls
1. Each person upon whose behalf this application is made & each person'ai
��hose request and for whose benefit work Is.performed und6r or pursuant.to,,,
any permit,lssued as a result of this applicaton agrees to, &,Shall, Indemnify'
9 hold harmless the City of La Quinta, Its off Icers, agents and employ6e's.,�',
2. Any permit Issued as a result of this application becomes null and Vold If
work,is -not com menced within 180 days from date of Issuance of'such.
permit, or cessation of work for 180 days,wlll subject permit AD 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'heraby authorize representatives of this City to,'enterupon
the. above-mentioned property for inspection purposes.
Sinnature' `--ADat
BUILDING PERMIT Vol
DATE VALUATION LOT. . TRACT
JOB SITE
OWNER
CONTRACTOR DESIGNER ENGINEER
62
USE OF PERMIT
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INSPECTION RECORD
OPERATION
DATE 7
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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I 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
Sewer Connection/—�" 1
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
` HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
1, (760)360-7448
-"
(760)321.-7448
CUSTOMER'S ORDER NO.
DATE RDERED
�_ 7 �-L Z
ORDER TAKEN BY
DATE PROMISED O A.M.
0 P.M.
BILL TO^--/�
i1/ � ` v (�
i J
PHONE
ADDRESS
�
MECJ� IC
CITY
HELPER
JOB NAME -AND LOC TION
-DAY WORK
❑ CONTRACT
❑ EXTRA
DESCRIPTION OF WORK
n \C
ale, --7
(� (�
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
t
Gallons
' ®
Pumping Fee per 1000 gal.
rig'60
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 Q
TOTAL
LABOR
I hereby acknowledge the satisfactory
completion of the above described work:
TOTAL LABOR
TAX
SIGNATURE
DATE COMPLETED
-TOTAL
F