0402-120 (ELEC) LICENSED CONTRACTOR DECLARATION ? BUILDING PERMIT PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT CJ,1A1;k- 'f) TRACT
04 W Professionals Code,and my License is in full force and effect. �.
O =) M License# Lic.Class Exp.Date
JOB SITE APN
P_d ADDRESS
672285 B r 6/30105 01-250,f�'klENU 62
oZ r Date fit' Signature of Contractor OWNER CONTRACTOR/DESIGNER/EN (NEER
W 9I
J
i.-
OWNER-BUILDER DECLARATION SHLALAQUI31.4-T.A1�' Lei-1F-kLA.(;ITV.r,,A 3J�-
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's t312(,l�A1rgt�i)E F 8226y - ref i�2
F- U) License Law for the followingreason: ,
Z ( ) I, as owner of the property, or my employees with wages as their sole LA,Qf.MY A Ck? s'223� L.rtl:�iI,E23-6 C.A 92253compensation,will do the work,and the structure is not intended or offered for (7>;f�17 7`1-S4t05 C:T�X.�# TBD
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 & ProfessionalsIPC"I'�tIG/izr i
Code).
co () I am exempt under Section , B&P.C.for this reason T'k:t P K'UiNER POLO FOP,CflNSTRUCTI014 YARD BILI
LO
N Date Signature of Owner
OC\I
CL Q WORKER'S COMPENSATION DECLARATION
p Ir 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' VALUATION 1,gOr3.fi0 I's
X W u- 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 r) (") I have and will maintain workers'compensation insurance,as required by
O U Q Sgction 3700 of the Labor Code, for the performance of the work for which this
Il U-)
Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
Cb O NATIONAL UMON 7165811-Q EN]'i"TFID CWT OFt'.ONSM17C"TTON 15I. 00
Q (This.section need not be completed if the permit valuation is for$100.00 or less).
1-TRAU.T Yfeb:N1TWAE4R
J ( ) I certify that in the performance of the work for which this permit is issued, ELECTfiWAL FEE 101,0170.420-000 $30,00
1 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 forthwith comply.with those provisions.
Dare. i t ' Applicant
Warning: Failure to secure Workers'Compensation coverage is unlawful and D Li
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. FEB 11 2004
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 CITY OF LA QUINTA
application. I FINANCE DEPT.
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 SUJI-fcJTAL COWi'RUC3TOW WD PLAW Vi MCK $30.00
any permit issued as a result of this applicaton agrees to, &shall, indemnify LLr`13 PPS.-PAM MMS soo
& 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
work is not commenced within 180 days from date of issuance of such MTAJ.P1!`-RIYUT FAMS llITY,NOW
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 I IIIIIII I III III I III IIII 32
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon ` IE ,
the above-mentioned property for inspection purposes. j
) 1 , RECEIPT DATE 1 BY ATE Q LE INS TOR
Sig an lure (Owner/Agent) ��'"''` Date i 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
Underground Pibg.Test
Final Gas Piping
PLUMBING APPROVALS Elecc F
tinal
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
I Final
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVAL
,12
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(Penn)