0003-130 (ELEC) s LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
CO I hereby affirm under penalty of perjury that I am licensed under provisions of t3t►f!3 t341
F— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE 4)3J3JZU1)VALUATION LOT LOT TRACT
C14 W Professionals Code,and my License Is in full force and effect.
License# Lic.Class Exp.Date
W � 2 52 580 Ci0 041301201 JOB SITE ADDRESS W159�1,V:t':'�UE 50 APN
r` � , OWNER CONTRACTOR/DESIGNER/ENGINEER
c Z r` Date Signature of Contractor
CD O C '4''F:1111 0r".•t'l1 A40 I"'Y r;1� r ANI fi,Y l..��r"n 1(»�!!-'�
H OWNER-BUILDER DECLARATION °�""'"' ••�� s�T�T.•�•�� ;•
CD
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's SO 209 AVENUE 50 74-869 JON.!1)R1 ,T*
H a LA QUKI:A CA 02253 PALM 11.E3 Isi: l' CA 92261
License Law for the following reason:
Z ( ) I, as owner of the property, or my employees with wages as their sole (76(1)146-8342 0131.11 1043
43
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). USE OF PERMIT
(,,4) I, as owner of the property, am exclusively contracting with licensed Ri,2CFk10A1,
contractors to construct the project (Sec. 7044, Business & Professionals
Code). I' t d0 AMP.EIECTRICML Ss.;161CP PALATI ONLY(LOCr1T10N GIA1�9s:T
co () I am exempt under Section B&P.C. or this reasori / t f
LO
N D e��i A r r� Signature of Owner `"� / J ca1V1,Y1
Orn I `.. r 5�1!E'� ✓Y-'`'' s
Q WORKER'S COMPENSATION DECLARATION
CL
p 2 Z I hereby affirm under penalty of perjury one of the following declarations:
LO - O O 1 have and will maintain a certificate of consent to self insure for workers' v Ai.L`iT►ON 11,06.1M La
X W 4- compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers'compensation insurance,as required by
O U QSection 3700 of the Labor Code, for the performance of the work for which this
11 LO H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
ccb +'»l»"a ir�wrr A1+T rT�» »r , r uT n!��V rr» Y.S.''S'P 3* COST
T.` v(1 T`"M'Y ' 1"N T i '!/4 id
O A i�eaoa�•tvA { v°.rw IN �'i�tiv'lrt"uxv, a:Mrfl,Ae& '�'�'.�°iC�i,aa tir �..ii��Yc�u"� i4 �.�if�»:�•pr�f
Q (This section need not be completed if the permit valuation is for$100.00 or less). ilf-MJMIAT ' 'R Si1lMMARV
JI I certify that in the performance of the work for which this permit is issued, HLEC' RIC11kL H-i 101-000-420-0(NJ
I s&l 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,,6�shall forthwith comply with those provision ,f
Date: ? �APPlicant / ` k I ���n +P' ., C .4 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
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 SLfR TV:!FAf,MNS`E h.i i(7'1_0N ANT)T'T,A.Rf C3I F( K
& hold harmless the City of La Quinta, its officers, agents and employees. IX,SS 'PRE-11AID FEES
2.Any permit issued as a result of this application becomes null and void if t ,- s <`
work is not commenced within 180 days from date of issuance of such -2
permit, or cessation of work for 180 days will subject permit to cancellation. V01AL 1'R!'MMI T FFl[eS 044 MAW S52'1
IIIII�I VIII III VIII IIII
1 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 54
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned property for inspection purposes.
i
D INSPECTOR
RECEIPT DATE F AL
pign ture (Owner/Agent)r1 ,.,-�f""'
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 !
I
Final
Final POOLS - SPAS
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain
Bond Beam Approval to Cover
Equipment Location
Underground Electric 1
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
1
Final
Utility Notice(Perm)
11
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