0404-068 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
U) I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9(commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT TRACT
04 W Professionals Code,and my License is in full force and effect. t 410642M $7,4f1t11,)€i
O ch License# Lic.Class Exp.Date
� LO JOB SITE
Signature
A ADDRESS 81.-'T�'S R+.'�,I�U.�.�.58APN r -
ZO t iDate t? C' `t Signature of Contractor _r!t.� OWNER CONTRACTOR/DESIGNER/EN (NEER
co ti i.— C) OWNER-BUILDER DECLARATION C(3m.%ol''1'foll1,13,C V.ARKS C(}NSTlUC770Ai
W w I hereby affirm under penalty of perjury that I am exempt from the Contractor's BOX 295?�' RANCHOUl ''-1'�►13 i,
~ U) License Law for the following reason: 1A QLMJSA CA 92253 LA QjjDTTA CA 92253
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)771.1941 CS_UF 2 996
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
Code). CORAL MOUNTAIN SITE,,9t.Lp.CT.RICA1,SPRVIC IT ril (400A,277149i7V)
co () I am exempt under Section B&P.C.for this reason
N Date Signature of Owner
ON
0)d Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
r < 1,01 O O 1 have and will maintain a certificate of consent to self-insure for workers' �'P�Li11��1�3?7 7,4100,00
X W Y= 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.
CD Q (� ( ) I have and will maintain workers'compensation insurance,as required by
O Q Section 3700 of the Labor Code, for the performance of the work for which this
11 H permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier S'fA?P pUNT) Policy No. 046-7333-2003 MWA'iED G;OST OF MMTCIUCTION 71+00.00
°r° O P:�:!"c1!%3S'f FEE 9U11+ MARY
J (This.section need not be completed if the permit valuation is for$100.00 or less). KJASC TRIC..AL 7 9 K 101-000-420.000 $52,30
( ) 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, andlagreethat if I should become
3 subject to the workers'compensation provisions of'SectiD3700 of the Labor
Code, I shalA61hwith,comply with Those pr�sions. //
Date: 4�rc P /*r Applicant
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-T(YrAL 0,MWRTaC:T16!VA+D PUN Cf�:frM11, $52.50
.
whose request and for whose benefit work is performed under or pursuant to LHM MR-FAM FIM $0.00
any permit issued as a result of this applicaton agrees to, &shall, indemnify
& 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�`:�;.1�l�rT'�;�s FS��)�NOW $52-50
n
work is not commenced within 180 days from date of issuance of such } -,.. II
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 JrT.• _,�,., - -.—� IIIIIIII VIII III VIII IIII 59
correct. I agree to comply with all City, and State laws relating to the building „�,rr
construction, and hereby authorize representatives of this City to enter upon IE
the above-mentioned property for-inspection purposest -” .
� RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) Date "'
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 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 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)