0309-209 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
I here��,a der penalty of perjury that I am licensed under provisions of }
H Cha te�9 commencin with Section 7000 of Division 3 of the Business and �309 �
P ( g ) DATE VALUATION LOT. TRACT
cel W Professionals Code,and my License is in full force and effect. wa.�
O =) C) License# Lic.Class Exp.Date
Lf) JOB SITE
LU O6,"3(01 / (► 07/3112C ADDRESS 7.-9W t�.•VETM 47 APN 643-M-0116r I, /rt'i��17` f ry' ✓ ✓�'
o Z r-- ate OWNER CONTRACTOR DESIGNER EN (NEER
Signature of Contractor y. / /
t`
r*_ C:) OWNER-BUILDER DECLARATION VEAL&c�iy.t�z A,LLC CARRP'UIMERS
J U r- 45-524T0W..WE','frR :1' 39.301 �f3ADO-MR ST 311Y.rl7 300
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's
DMIOCA P2201 PALM DRITERT CA 92201
License Law for the following reason: r
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (?60);360-6632 CBL6. 1.395
compensation, will do the work, and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed oLngEpAy.1 C7IL �1C9 ,
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ISITIP I.ILIISTrN0 I:3 LIGHT STAN13A.RDS,2001: CODES
co () I am exempt under Section B&P.C.for this reason
N Date Signature of Owner
ON
O)
z
WORKER'S COMPENSATION DECLARATION
C) I hereby affirm under penalty of perjury one of the following declarations:
U-) � Ix O O 1 have and will maintain a certificate of consent to self-insure for workers' VALUATION
,5fl 'a4 1"�
X W compensation, as provided for by Section 3700 of the Labor Code, for the
Om _ Q performance of the work for which this permit is issued.
Q U ('Jr'I have and will maintain workers'compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
Zpermit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATEpt1NTl Policy No. 12428,24-02 ETF-0(-NWOFCONSTRUCT) ONob
J (This section need not be completed if the permit valuation is for$100.00 or less). MAN CHRCK FEE 101.000.439.518 �9U3,40
( ) I certify that in the performance of the work for which this permit is issued, CONSTRUCTION FM 101-000-418-000 $63.00
I shall not employ any person in any manner so as to become subject to the F1,,I TIUCAL FEE 10.1.000-42()-000 SM175
workers' compensation laws of California, and agree that if I should become
subject to the workers'compensation pro visio,n sof Section 3700 of the Labor STRfi�N'C?MOTION FE1u taF•SIR 101-000-241-000 x.30
Coded sh II forthwith comply with tho'se,pro isions..
Date: 7 � a'"*! Applicant
F
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.
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 YUB-TOTAL C-C) 'I°Rl!'t`.;"
M Mlq AND PLAN CH C.[C�
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 �;t_ 1 F03 PPM-PM)FI $0X10
& hold harmless the City of La Quinta, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void if TOTAL�'�.k$NIT.A FENS ME NOW $}93.2,'
work is not commenced within 180 days from date of issuance of such NOVN 8 2003
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 CITY OF I.A t5t6ENITA IIIIIIII IIIIIIIIIIIIIIIII 07
•
correct. I agree to comply with all City, and State laws relating to the building FINANCE DEPT
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned property for inspection purposes.
DATE BY / DATE FI ALD INSPE OR
'S. nature RECEIPT
ature (Owner/Agent) � ' �'r Dated
INSPECTION RECORD
OPERATION DATE INSPECTOR ; OPERATION DATE INSPECTOR
A BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs 4 Underground Ducts
j orms&Footings S 03 Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Ex-a24 Fans
O.K.to Wrap F.A.U.
Framing Compr r
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans&C ntrols
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath w'
Final
Final POOLS - SPAS
BLOCKWALL APPROVA S 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
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)