9606-102 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT# CONTROL#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of 3553
F- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT W16-1412 TRACT
C\1 W Professionals Code,and my License is in full force and effect. 6/19/96 S28,¢i0(3,11413
O Z) M License# Lic.Class Exp.Date
C) U) JOB SITE APN
r` ELIJ r r , 41:.32 / C-10 Y311198; ADDRESS Tai-880 AVENUE:w
ZZ P Date4l ��K&gnature of Contractof/^ :,r ` ,C OWNER CONTRACTOR/DESIGNER/ENGINEER
J U °� OWNER-BUILDER DECLARATION LA QUII`1'1'A MIDDLE:SUit?OL DAVIT.}-R7C'}•#,ARDS IiI.C:CIXIC
W W co 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's 74-880 AVENUE 30 lal E. DM'E PLACE
~ U) License Law for the following reason: 922 ;
cn g t,t1 t�1{IN'1'A t:A �..5"� tit1N 13f_kNARI3iNty CA 9140A
Z_ ( ) I, as owner of the property, or my employees with wages as their sole 1 >if;R1-�td94 C 131
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
contractors to construct the project (Sec. 7044, Business & Professionals I;I LC,f R AL
Code).
CY) () I am exempt under Section , B&P.C.for this reason
N AUU 13;f.1C'i1TrS'ro LA QUINFA MIDDLE S�"1�t(:►OL I'lli�1,l)
O N Date Signature of Owner
0)U Q WORKER'S COMPENSATION DECLARATION
C aZ i'UN1tCAt 1' �f�XiJt)fVl a,(KPJ.(M1 Lh
) Cr I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O ( ) 1 have and will maintain a certificate of consent to self-insure for workers'
X W tL compensation, as provided for by Section 3700 of the Labor Code, for the
m � Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers'compensation insurance,as required by
pU Q Section 3700 of the Labor Code, for the performance of the work for which this
H permit is s, ed: My+`w,ork s�..Yompensation insurance caYl0 r 1, wno. are: F,.S'1'i1t4A'3'EJ)(4S'1'UIP C.OIti%rfRUCIJON 28.000.00,ItZ Carrier Policy No.
000 d 11P,HIMIT 14%StlMMARV
J (This section need not be completed if the permit valuation is for$100.00 or less). 171•FC'3RI('A1.FE E 101-000420-000 1;114.75
( ) 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
3 subject to the workers'compensation provisions of Section 3700 of the Labor
Code, I shall grthwith comply with-those provisions.
Date: 5Applicant• "�'•-� +^
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 is-�1' i�AL CONS'ITtUt'"1 ON AND Pl&N C1IUCK $11-1115
whose request and for whose benefit work is performed under or pursuant to /�\\
any permit issued as a result of this application agrees to, &shall, indemnify / l }"sS5 111(F-PAID 1 FEES 00
& 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 I• 1 T4 TAI.PERM1 l' DUI;NOW SI 14 75
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. Li
I certify that I have read this application and state that the above information is ^�r I Illl�l�lllill�l IIIIIII
• correct. I agree to comply with all City, and State laws relating to the building I 27
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned property for inspection purposes.
Y RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) -�� +� - -�_ _ Date /fes^
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 Wail 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 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)