0210-142 (PLBG)LICENSED CONTRACTOR DECLARATION
..Hereby affirm under penalty of perjury that I am licensed under provisions of
"6hapter 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
4'15515 AWHIC � OeJI'301yi
pate 10 7 � 6 "-Signature of Contrac
OWNER -BUILDER DECLARATIOrt;I
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 SUATL. FVND' ' Policy No. 044-02-00I.V98
(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 sh I forthwith comply with those provisions.
Date: iu %"" �� Applicant
Warning]Fai ure to secure.Wcrrkers 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. �A�_ rSignature (Owner/Agent); �, ^/ - Date /4
f. �✓ �" ....� --
BUILDINGPERMIT PERMIT#
Ea1'.0-142
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS 51,^t 5 AV9.1MRRREr.I'r.A
APN
7734"aMS
OWNER
CONTRACTORIDESIGNER 1NgE�E.}R
yRpyy
AAR. & MRS, L LS MORALE'S'
r/�Es�Nr
.i dW. 471..•Y'lP. v�.XV l7 b S�iA Z'.0 A3d`f I . ; , • '
51-865 AV& 11ERRFi t� A
34.7 aC DAIS PAILIADRIVE
LA QYIJ ITA CA 92253
CMIWORAL MT CA', -92.',:.1
;i o) 2•i-�E3 E1 05114: 7C2
USE OF PERMIT
MPTI C:.{b.Ffr2A1DON, SMER HOOK.UP CLDIV-MOD P6tO.fltXT n0i124Z,
VA:.d1A TION ,SRp_Do W
('0Fr OFCt)Sdb"'.t'C���l'C'��xs,��
2140D,f?)
g-4;..,ygE9Y:MR.�..r.1D
JY?.iLa�:4116JL �E1+SG'� e"i4a.Y9��AT;n�11.S
' ' ..::; 'h ; 101-000-419-000
st
�f ' `1
M• . MAL COIa1WAUC`:l° 014.AND I-IIJ14 C!1 ,LvX
$30.00
_ U01; PIM -PAM 1E:q
$(0
�
VrpY 4RT.++t IrFXt S tTt» NOW
WAX)
OCT 2 2001.
WYCIFLAGUINTA
_ FINANCEDEPT.
RECEIPT
DATE
B1'
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 & 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
jA ,proval#o Cover
Squipment Location
Underground E1e6tric
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
Encaps tion .
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
17an1,2an-7ddn
(760 321- 7448
CUSTOMER'S ORDER NO.
ATE ORDE D��
'
ORDER TAKEN BY
DATE PROMISED 0 A.M.
0 P.M.
BILL TO .4-9 6c.
�•}
PHONE
ADDRESS
ME' NIC,
CITY -5 —
�S
HELPER
JOB NAME AND LOCA(I
✓fit `�
�•S��y!
❑DAY WORK
0 CONTRACT
0E%TRA
DESCRIPTION OF WORK/
Z- I +
QUANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.
7
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:6
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 TOTAL LABOR
completion of the above described work:
TAX
SLQNATURE
�, �,)
DATE COMPLETED
I lj,4 ()7_
TOTAL
`
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