0301-268 (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
i c14 W Professionals Code, and my License is in full force and effect.
O :) M License # Lic. Class Exp. Date
CY LO
LU
cZ � ate �'!�� Signature of Contractor
co 0.
J U C) OWNER -BUILDER DECLARATION
LU Luu I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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).
cO () I am exempt under Section , B&P.C. for this reason
O N Date Signature of Owner
rn
Q WORKER'S COMPENSATION DECLARATION
p Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo .Z O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
m Q U ( ) I have and will maintain workers' compensation insurance, as required by
b Q Section 3700 of the Labor Code, for the performance of the work for which this
H permit is issued. My workers' compensation insurance carrier & policy no. are:.
Z Carrier a'%11'f IF, .M Policy No. 044-3%-i1OWNS
ob
�O
J (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 37 0�bf the Labor
,,'Code, I shall forthwith comply with tho a provisions.
Date: Applicant-
Warning,-
pplicant 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. r
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 O f'this City to enter upon
the above-mentioned property for inssppe`ctionn rpose .
/ Signature (Owner/Agent) Date l /7, ='
BUILDING PERMIT PERMIT#
DATE VALUATION LOT W01-2601 TRACT '
JOB SITE APN
ADDRESS
51-537 AV9a r0A IMM- KRA
OWNER CONTRACTOR / DESIGNER / EN (NEER
117. GL LACY TM BAR C:O:tJMRUM014
T,..A, Q111M:A. CA 92253 CATM DRAL CT1 Y CA 92235
Q60)321�0898 Chi9 762
USE OF PERMIT
Y.1X !MR1%1G3
u;F TKs 11ftANr3(7N, =Wzkl HOOK-UP
VAE,UAi%ON ,
I
JAN
E.3 CITY OF LA
MrWATM COST OF CONS-MRNTOX
-}"I.Ej3t01W) FFIE 103-000-419-0001 SAM
;1;
s7VJ::-TOTA,. CO. M�. id��'.IIO AWD 8,'".l-'lIM CHECK
LE- 33 PRR--T?AH') FRE!
2101301W
$30.00
$0,00
TOT AL Y III V)VES D4 E NOW M.00
i
RECEIPT DATE f / y BY j`/' s DATE FINALEDr/� 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 & 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 Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
_
Encapsulation
.Gas Piping
Gas Test
Appliances
Final
Final iQ
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lxwv Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice tPerm)
COMMENTS:
HAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
earn 2an_7ddn
�.....� v... -..v
(760) 321-7448?�
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE DERE/
�a
Gallons
ORDER TAKEN BY
DATE PROMISED 0 A.M.
POCQ
Pumping Fee per 1000 gal.
0 P.M.
BILL TO (1
n---
PHONE
J Ci
ADDRESS
ZPIOOV
MECHANIC
CITY
HELPER
JOB NAME AND LOCATION
3 7
ve
0 DAY WORK
._/—
Pra c .
DESCRIPTION OF WORK
❑CONTRACT
0 EXTRA
v f /
v
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
POCQ
Pumping Fee per 1000 gal.
/19,0
n---
ZPIOOV
Dumping Fee per 1000 gal.
/0C
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 C)a
HELPERS Q
TOTAL
LABOR
I hereby acknowledge the sakis�etory TOTAL LABOR
completion of the above described work:
TAX
SIGNfTURE��
C"'b°/1
DATE COMPLETED
TOTAL