0012-215 (PLBG)LICENSED CONTRACTOR DECLARATION,'
I hereby affirm under penalty of perjury that l' 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 '�. Ex 'Date 'A
l9to i' Signature of Contractor
OWNER -BUIL DER.DECLARAT ON
I hereby affirm under penalty of perjury..that I am exempt -from the Contractor's
License Law for the 'following,reason:
( ) .1, 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 .
Code).
O I am exempt under Section B&P,C. for this-feason
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
pert rmance of the work for which this permit is issued.
f ) 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:
Carver Policy.No.
(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-anymanner so as to become subject to the
workers compensation laws of California, and agreelff attif I should become
sub ect to the workers' compensa Ion provisions of Section 3700/6fAhe Labor
C • de, I.sh II fo iwiith comply Wit 'those:.provisign J' `
te:! �.:. Applicant't:
Warning: Failure to secure Workers' Va�tpiesnsation coverage,is unlawful and
shall subject an employer to criminal pand civil fines up to $100;000, in
addition to the cost of compensation, damages as provided forin Section 3706
of the Labor Code, interest and attorney's fees. 4
IMPORTANT Application is hereby made to the Direcfor,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-requestandfor.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 -1 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 representafives of thisfCity to enter upon
the a • ove-mentioned pE!r !pertyforr)inspe(ctttiion purposes'
1 "
S gnature (Owner/Agent). j,G/fix!"'Date
- PERMIT# '
r BUILDING PERMIT i
4
DATE VALUATION LOT . 00I.V4 S-4TRACT
_
JOB SITE
APN
ADDRESS a'�,� 1 QS�i A�/°.C'O. �•'SGcF eE.
P' i -III
OWNER
CONTRACTOR/ DESIGNER /ENGINEER
h'R.. mm wa. KL. rru co �,�i`rox
iD�limonz �1`��L�llal l�i'Li� o- a Comm.
a��1 r ac •�rx z' .
686-M :MM c oulfir
1A QU'1-n4 CA 92253
CKMEDRAI CffY CA 97234
I I.SF OF PFRMIT
�'7t�6.73VLt'�,�1•C� '
SAPTIC'ABANDON. SEWER CC, W1.1l?CT. ;i.C7W:MOD ??3dOM't' 2600.21.
A
t
VALUATION ` ' 1,E.QS.Ot! t
7at;SI7t�!•An C� 11r OF CON'S"11<tUG''7l" OR
PRMVr FM 9uhGA sR'
i'1.UMS1140 FEE — SE' VER 101.000•#19uDOO
R� B-AYr'AL Ct3�1`�'3:`.� U 1'�C0K AIM 1%1:-: A! "1t
$30.00
1?1 isap� FW
,
RECEIPT
DATES ,,
.r�_��� fir,
BY•" j
;r,.f• '.
DATE FINALED
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
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 Hacks
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
OX for.Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection �_((� p ( S i
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
,p(Jp*4v Yt C (G E 7
Final Q
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.
P.O. Box 2448 _
CATHEDRAL CITY, CALIFORNIA 92235-2448
(760) 360-7448
(760)321-7448
JOB INVOICE
CUSTOMER'S ORDER NO. DATE ORDERED
-D l
ORDER TAKEN BY DATE PROMISED ❑ A.M.
0 P.M.
BILL TO
^
PRICE
AMOUNT
PHONE
ADDRESS
MECI;{ANIC
CITY
HELPER
JOB NAME AND LOCATIO�jJJ
/. f G
r
/ T V C... U s
�'
a6AY WORK
❑ CONTRACT I
DESCRIPTION OF WO
'
❑ EXTRA
Out of Area Fee
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
00 ('
Pumping Fee per 1000 gal.
0,9v
Dumping Fee per 1000 gal.
Out of Area Fee
'-"
Locating / OpeningFee (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 @
LAOBOR
I hereby acknowledge the satisfactory TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE
DATE COMPLETED
//1-/0.(,
TOTAL
) c 3-
o