0312-188 (ELEC) LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING,PERMIT
HChapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT WJ.2-1'8a TRACT
04 W Professionals Code,and my License is in full force and effect. : 2/18/2 : ':2.,('"0 0t1
O =) M License# Lic.Class Exp.Date
r— CY LO -�ry� !! JOB SITE �yyq� APN
I\ '/�` 69307 � r✓Yd:a�lit:F�. ADDRESS 78•9W.'�.VENUK47
r` Z / Date Signature of Contractor OWNER CONTRACTOR/DESIGNER/EN (NEER
CD 0'�
r` P: p OWNER-BUILDER DECLARATION VMT1•�L.t�.C1LMgl' ;I C t31�tBMT-DYRS
H d r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's 45.524 TOWNE ST•1`M 39-301 B ADGIRSi`T 31H.17 w 300
License Law for the following reason: DM10 C� 92201 �'l�LMD&MRT %�� 512201
Z ( ) I, as owner of the property, or my employees with wages as their sole twno 1395
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 IIIIIIIIIIIIIIIIIIIIIIIII
contractors to construct the project (Sec. 7044, Business & Professionals GIN'L XL BUI DING 04
F
Code). SITZ'1:3.0 HTING-2 AD2L�ITION.,k .-L.101fiT S'IA1.+OA.Rt),H,2001 -- --- IE l Ji
ce O I am exempt under Section , B&P.C.for this reason ,-
N Date Signature of Owner COT»' /CDD��'PPROVAL 13ER,1� IIERM 14 014 is l�-2001
ON
Q WORKER'S COMPENSATION DECLARATION
C:) Cc Z I hereby affirm under penalty of perjury one of the following declarations:
Lo H O ( ) 1 have and will maintain a certificate of consent to self-insure for workers' �',Ai�f��`11CZN ,RDn'CFA US
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
O 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 o3,rAyg FUN-F) Policy No. 12429 $-03 D COST b'OF c{.3N.ISTR irl-MO�7 2,000,0 0
C) PS-1041T FEE S'YTMMARY
J (This section need not be completed if the permit valuation is for$100.00 or less). PLAN GHhwK FW. ]U3-UfJU 439-315 - $29.23
( ) I certify that in the performance of the work for which this permit is issued, CONSTRUCTION FEE $45.00
I shall not employ any person in any manner so as to become subject to the e r
workers' compensation laws of California, and agree that if I should become ELECTRIC.ALFE 1#1.0)301"!A2��E3'�0 $16,50
3 subjec.146 the workers'compensation provisions of Section 3700 of the Labor STRO}ittMOTION FEE,RMILI $.50
C,ode I sh I forthwith comply with•tho`se p ovisions � {f
Date: j� 1�M'2 7 Applicant .�i%r`e.� ,0%• /�. 'f
d
� 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 qONSTRIM10WAIM PLAN $91.2' 5
whose request and for whose benefit work is performed under or pursuant to n
any permit issued as a result of this applicaton agrees to, &shall, indemnify u I°.1♦3 PRE-PAID MUMS ` 0'0Cl
& hold harmless the City of La Quinta, its officers, agents and employees. (ri1
2.Any permit issued as a result of this application becomes null and void if D 1$ ZQ03 L,PERMT71'1 98 DUE NOW
work is not commenced within 180 days from date of issuance of such 1i
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 4gtlt"+�E�`
• correct. I agree to comply with all City, and State laws relating to the building CITY %C. 01,;! a
construction, aril hereby authorize representatives of this City to enter upon f"I�fQ+ C.
the above-mentioned property for inspection purposes. ! / /
�r RECEIPT DATE BY ( DATE,FInALD INS PE R
Date
Signature (Owner/Agent)
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&FootingsDucts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
OX 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 APPROVA S 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
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)