0012-212 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9•(commencirig with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
/te
se # Lic. Class Exp. Date
8$45631t .ABH f M31 2 t 2
} t ? �~?'� Signature of Contractor
OWNER-BUILDER DECLA9.0I0N
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 Sianatuee 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•foe 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
Se�cflon 3700 of the Labor Code; for the perfoemance of the work foe which this
permit is issued. My workers' compensation insurance carrier &policy no: are:
Carrier Policy No.
STATE FUN%)' : 4?�14•Diaw"itl4aB�'
(This.section need not be completed if the permit valuation is for $100.00 orles s).
() 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 agreethat if I should become
sub'�ct to the workers' compensation provisions of°Section 3700,.of the••Labor
Code, I shall forthwith comply withithose p'rbvisions.
Date: L :'J APPlicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal peJlties 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 thigtity to enter upon
the
above-mentioned property'for inspection purpo�
4$19nature (Owner/Agent Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT RACT
JOB SITE
APN
ADDRESS
52-080 ,A.VFNTDA. X11IMMMR'lc'
773.231.-M9
OWNER
CONTRACTOR/DESIGNER/ENGINEER
L° LIA.8MRIM l9ld•I)AU.RTANAARWDOZA
DMWER 096: THMU 0 & CONST
12.0180 001"FlI :TOWEI .
66-175 DMON COITAT
t Q%td rfA CA 92253
C:'tsME DRAL. C°9`i`Y CA 92234
(i6Ct)37.7- 2t3U C"BTX 3577
USE OF PERMIT
SEPTIC .ABAN130N. SEWER CONTMt~'M WW -MOD PRORMT 2000-'L;:,
VALUATION .11300.00 LIS
� T A1% 0;43 1' C)1+' C°C31'd 'l"idUC l OXO
1, {DA i
"MWT FM SUMMARY
:t�Ltti��3Tj;�C3�.. �3�11?F� Iti?a{2�-4I9�i�'ift $,'j�,It>a
S B-9TMAL C�'?t STR UMIONT AND RLAW Dim M
$30A)
1X33Y Y k'RE-PARD YE S
Scs.QU
IrOTA a PKRMrr1rX= DIM ,tr Qvi .MAX)
RECEIPT
DATE.,
BY . `
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
POOLS - SPAS
BLOCKWALL APPROVALS
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. / 3 r
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
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)
HAMMER PUMPING INC. roe INvoIcl
P.O. Box 2448
CATHEDRAL. CITY, CALIFORNIA 92235.2448
r+fef% aGA 7AA0 - _
(760) 321-7448
- -
CUSTOMER'S ORDER NO,
ORDER TAKEN BY'
DATE ORDERED
ATE PROMISLD O A.M.
I M
PHONE
,ADDRESS ..
MECHANI�
HELPER
J06 NAmC• AND LOCATION ` O G M
a V ljl/
DAY WORK
CONTRACT
DESCRIPTION OF WORK
rQtM\
0
0 EXTRA
ANY. DESCRIPTION OF MATERIAL USED PRjcE
AMOUNT
Gallons
Pumping Fee per 1000 gal.
;S
vut ur nI cv rvv
Locating / Opening Fee (per hour)
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
HELPERS ®
LABOR
I hereby acknOwlcdgc the satisfactory TOTAL LABOR
completion of the above described work: TAX
31 .NATURE fiATE CO PLETED
TOTAL