0110-224 (PLBG)FI
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. Cls,'-"-` � xp~D to e' r
+tt'e SE. •A3 t . ABB
Date �€ I x/# Signature of Contractor
low 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
aS ction 3700 of the Labor Code, for the performance of the w_ork.for which this
✓permit is issued. My workers' compensation insurance carrier 4*olicy no. are:
Carrier vi� U 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 any,manner so as to become subject to;thef
workers' compensation laws of G'alifornia,; and agree if I should become.
subject to the Workers' comperfsation provisions'of Section 3 ,00 oftthe Labor
Code, I soallEforthwith complsy wit °those provisionlls. t''�
Date: , / 3 s � f) i Applicants , ?�� t. ,
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer io 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 .Y
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 hereWauthorize representatives of this City to enter upon
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the above-mentionediproperty for inn/spedofn purposee� / e f v
Signature (Owner/A�/gent),.o±�%+`✓� :°`Date
G
BUILDING PERMIT PERMIT#
DATE S� 1 VALUATION LOT 0110-214 TRACT
JOB SITE
APN
ADDRESS _7g.,110 CA O iXNAb.
770
<Tii 454-00
•bWg&N,,,E'5SR
CONTRACTOR // DESIGNER
i.����� ((y �g7 �y'(y
Sf R. r�rc. 1 , �A •a.OR.
�g/ENGINEER l e1 /.
AJE'..x�S7�'ElRM..L`N173SV:C�iRJXG &I COMEST
�'.
'J6-170 i . 14X)RTTYR!,
4,575 � C•f!3aii.�:�® P.t ROCKfr11
,'LA Qp.i.2m CA 9225.3
11JALM fii`.e 81903 CA 922(A
�
i ii)3, `?•2�. (� �; € 577
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USE OF PERMIT
5.:�,s''i3C"".A.�a�,'ts03:'�'t3, S.fr:'��f�l� I30t�iC,Cf�' (l'.�CY�tT•P/lQ.l::i P3i:OJP"::P 2t9Qi�Wdj -
VALUATION W11
D �vM1�Lf''A.•�.i'.tl:'` CYJ'A la.Y.isV1u.�`•d.X`h 14
"..,�yR.n.i' 100
�y�+ye -�SyA C.�yNyVdAi:X.V.d2�d.<
�+y ryp�q FEE
X: J,CI.R"ef, T F Ere• 6: 9Yi.f+.�.(I+.Av.(#R ]i
PLOWING PEP 4 01-000-419-000
NOV 28 2001
.� f. B --TOTAL C01? tT rC T10,1y AND D PATI CPU=
� SCb.00
p FUpC
LUSS
..1GJ. AL �`,�4:��iiAT IMUS DUK NOW
&WAR)
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RECEIPT
DATE;� � fF. /'�
V / '
� ,"--v'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTORS
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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top O.ut
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer LateralPool
Cover
Sewer Connection
V, --270=-0-=
Encapsulation
Gas Piping
Gas Test
Appliances
;^U 1
el
Final _
Utility Notice (Gas) v `�
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)
Final
COMMENTS: -
HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
17=M QCA_7AA4
QUANT.
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE;ID
(760)321-7448
1)
Pumping Fee per 1000 gal.
,
ORDER TAKEN BY
d TE PROM D ❑ A.M.
f,,�iv
Dumping Fee per 1000 gal.
❑ P.M.
BILL TO
PHONE
ADDRESS
Out of Area Fee
MECHANIC !-
CITY
HELPER
JOB NAME AND LOCATION
�
/70
Size System:
D DAV WORK
❑CONTRACT
DESCRIPTION OF WORK
r,
❑ EXTRA
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.
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
f,,�iv
Dumping Fee per 1000 gal.
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 Q
TOTAL
LABOR
I hereby acknowledge the satisfactory TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE
-
DATE COMPLETED
TOTAL