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9605-080 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT# CONTROL# H I hereby affirm under penalty of perjury that I am licensed under provisions of 94M— 90 3333 Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE 5/,1a5l9G VALUATION a2.( NLfFA . LOT TRACT CV W Professionals Code,and my License is in full force and effect. O ::) M License# Lic.Class Exp.Date LU T 1 61.oi BI O V96 JOB SITE ADDRESS 134E-409 AVENUE 50 APN 769.270 1020 ,CC OWNER / / Z Date) ' `� ' Signature of Contractor Ir.0 ,� •�' CONTRACTOR DESIGNER ENGINEER } v K Frrl l&WANDA 11131 SP K I:T!'1•.i'it l f;SF1 t3ENJE 2 Al.CONT. (O ~ °� OWNER-BUILDER DECLARATION _JU 80'209 AV ii,Fr 50 80204 AVE,50 W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's j,q (lt f1N1'r� ( A u� S jNlafE? i;A 92201 ~ U) License Law for the following reason: ; .fi.ti�f3{) tli]�;1Sfi=l-3f+R0 CALF 301-1 Z_ ( ) 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). USE OF PERMIT ( ) I, as owner of the property, am exclusively contracting with licensed j;1,(; VR(CAL contractors to construct the project (Sec. 7044, Business & Professionals Code). INSTALL g lM1'l:OCIR f.I01i V;FOft t3b1MNY'A11r) LO M () I am exe pt urade. Section B&P.C.for this reason O N Date Signature of Owner rn Q WORKER'S COMPENSATION DECLARATIONIL C) Z I hereby affirm under penalty of perjury one of the following declarations: LO p ( ) 1 have and will maintain a certificate of consent to self insure for workers' X W compensation, as provided for by Section 3700 of the Labor Code, for the O J Q perfo ance of the work for which this permit is issued. m Q U (7I have and will maintain workers'compensation insurance,as required by O V Q Section 3f7,KHhJ..,Qthe w1Labo}�Code, for the performance of tW woyk*or w`i#h this �; '�� �� ;'D{�,d) � +.CZ�eNNTR�1�.•..RONN li rn H permit is issued. My workers compensation insurance Carrier& policy no. are: " Z Carrier Policy No. Ik'F!:Htlfi':1''it VF,Si►NI.iY'tARY ob d f AC-MICAT.FEE 1014XV-420-Wo Q (This section need not be completed if the permit valuation is for$100.00 or less). ( ) 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 provisio�nS of Section 3700 of the Labor Code, I s al f rtta, ith comply with t se iso Ions!' Date:` r�J� Applicant oT_' 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 SUB-10TAL CONS".fttUMON AM)PLAN CRECK. $18.75 whose request and for whose benefit work is performed under or pursuant to LESS. PRE-PAR)FEES $0.0o any permit issued as a result of this applicaton agrees to, &shall, indemnity "- & hold harmless the City of La Quinta, its officers, agents and employees. I 0 'O' ,.I,E,RN T.�'R,RS 00 E,NOYY '�4 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 10AY 1 6 1996^ I certify that I have read this application and state that the above information is IIIIIIIIIIIIIIIIIIIIIIIII 56 • correct. I agree to comply with all City, and State laws relatingto the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property f r inspection purposes. IE jJ RECEIPT DATE BY DATE FINALED INSPECTOR Signature (Owner/Agent _ ` " crt Dat5W640`6 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 , 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 APPROVALS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground PI .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 �� g��,c_. (, L 7 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)