9511-076 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
W Section 7000) of Division 3 of the Business and Professionals Code, and my
O in License is in full force and effect. 684563 �J9fi'
n W License # Uc. Class Exp. D
r- Date) � �p natureoRcontractor A
�Z�
coo � 0 OWNER -BUILDER DECLARA N
J W I hereby affirm that I am exempt from the Contractor's License Law for the
�,.W following reason:
U7 ( ) I, as owner of the property, or my employees with wages as their sole
Z 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
CY) Date Signature of Owner
N
rn WORKER'S COMPENSATION DECLARATION
d Q I hereby affirm under penalty of perjury one of the following declarations:
Z () I have and will. maintain a certificate of consent to self -insure for workers'
LO
�O compensation, as provided for by • Section 3700 of the Labor Code, for the
X W _ LL. performance of the work for which this permit is issued.
O J J ( ) I have and will maintain workers' compensation insurance, as required by
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
O U permit is issued. My workers' compensation insurance carrier & policy no. are:
d rn Carrier STATE FUND Policy No. 1.396640
'I z (This section need not be completed if the permit valuation is for $100.00 or less).
co :)() I certify that in the performance of the work for which this permit is issued,
Q I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Califo n 'ran`2� agree thatX-I should b ome
subject to the workers' compensatgn provisions of action 3700 of ttia or
Code, I shat fo with comply withcth se provisions
Date: %2 '7 1r Applicant
Warning: Failure to secure Workers'CompenCdn 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, intarest 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 res i(k of tth�is�ap rlication agrees to, & shall, indemnify
& hold harmless the City of Indian Wel; its officers,' agents and employees.
2. Any permit issued as a result of this application becomes null and void if
i4 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, o nspection pure s. C
Signature (Owner/Ag
""'_BUILDING
PERMIT
PERM'T95,-1-L16
DATE "j O
VALUATION 517q777 TRACT
JOB SITE ADDRESS 53-1315 Air WWA 1E.RPWRA
APN 774-10-017
i
OWNER
CONTRACTOR
DENBOER FWGINEER:INO & CONST.
100 A & MICHELLE CAN aPBELL
68175 BERROS COUtT
33815 AV NIDA. HERR.ERA
CKTHEDRAL, CITY CA 92234
L.A QI q CA C.A. 92253
(610327=2:200 CU# 3571
DESIGNERIENGINEER
USE Of PERmPLUIV1131INki
SHWFR CONT',' ECT
FEE DESCRIPTION
FEES
CONTRACT AMOUNT 1,742.00 LS
EST WATEID COST OF CONSTRUC'!'RON
1,742.00
PERMIT FE E SUMMARY
PLE.T(4tBING• F'BC -- SEWER 101.000-419-000 $:30.00
SUB -TOTAL CONS'CR.UCT[ON AND PLkN CHECK
$30.00
LESS PRE -PAID PEES
$0.00
TOTAL D,',F:[tMIT FEES VUE NOW
53100
IRECEIPT
DATE
BY
DATE RNALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
)NSPECTOR
OPERATION
DATE
INSPECTOR
-a
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
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
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:
TRI -STAR CONSTRUCTION
P.O. BOX 542
CATHEDRAL CITY, CA. 92235
ph. (61.9) 32170898
fax. (619) 321-7798
TO; CITY OF LA QUINTA
PER MY AGREEMENT WITH TRI -STAR CONSTRUCTION• I WILL RE -SEED OR
OTHERWISE COMPLETE MY YARD AFTER THE INSTALLATION OF THE SEWER.
THANK YOU,
please print name
+IAMMER PUMPING INC. JOB INVOICE
P.O. Box 2448
CATHEDRAL CITY, CALIFORNIA 92235-2448
\Vi.7J J%pw-f W
(619) 321-7448
DESCRIPTION OF MATERIAL USED
CUSTOMER'S ORDER NO.
DATE ORDERED
1 — _ q t.
ORDER TAKEN BY
DTE PROMISED ❑ A.M.
❑ P.M.
BILL TO
r� —
PHONE
Pumping Fee per 1000 gal.
ADDRESS
985
o0
r
M HANIC
CITY
HELPER
l
JOB NAME AND �LIOC`ATIIONN
3 (J ! 3 /� -t r ^ (�"
//
[iii
WORK
DESCRIPTION OF WORK
y(
❑ CONTRACT
0 CO
❑EXTRA
(''+
4
Out of Area Fee
DANT.
DESCRIPTION OF MATERIAL USED
PRICE
AMOUNT
O C O
Gallons
'bIV V
Pumping Fee per 1000 gal.
��
985
o0
r
s
►pCio
Dumping Fee per 1000 gal. T X
0rco
4
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR
WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
HOURS
LABOR AMOUNT
TOTAL
MATERIALS
MECHANICS Q
HELPERS Oa
TOTAL
LABOR
I hereby acknowledge the satisfactory TOTAL LABOR
completion of the above described work:
TAX
SIGNATURE
DATE COMPLETED
TOTAL
tv
NOTICE TO OWNER
Under the California Mechanics Lien Law any contractor, subcontractor, laborer, supplier
or other person who helps to improve your- property, but is not paid for his/her work or
supplies, has a right to enforce a claim against your .property. This means that after a court.
hearing, your property could be sold by a court officer and the proceeds -of the sale used to
satisfy the indebtedness. This can happen even if you have paid your contractor in full if the
subcontractors, laborers or suppliers remain unpaid.
To preserve their right to file a claim or lien against your property, certain claimants such
as subcontractors or material suppliers are required to provide you with a document entitled
"Preliminary Notice:' Original (or prime) contractors and laborers for wages do not have Lo
provide this notice. A Preliminary Notice is not a lien against your property. Its purpose is to
notify you of persons who may have a right to file a lien against your property if they are not
paid. Generally, the maximum time allowed for filing a claim or lien against your property is
ninety (90) Days,after completion of your project.
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY,
YOU MAY WISH TO TAKE ONE OR MORE OF THE FOLLOWING STEPS:
1) Require that payments be made directly to subcontractors and material suppliers through
a joint control. Any joint control agreement should include the addendum approved by the
Registrar of Contractors.
2) Issue joint checks for payment, made out to both your contractor and subcontractors or
material suppliers involved in the project. This will help to insure that all persons due payment
are actually paid.
3) After UPON making payment on any completed phase of the project, and before making
any further payments, require your contractor to provide you with unconditional lien releases
signed by each material supplier, subcbritractor and laborer involved in that portion of the
work for which payment was made. On projects involving improvements to a single family
residence or a duplex owned by individuals, the persons signing these releases lose the right
to file a claim against your property. In other types of construction this protection may still be
important, but may not be as complete. TO PROTECT YOURSELF UNDER THIS OPTION YOU
MUST BE CERTAIN THAT ALL MATERIAL SUPPLIERS, SUBCONTRACTORS OR LABORERS
HAVE SIGNED.