0111-111 (ELEC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date �� ji r Signature of Contractor b!a + ' t� 1( A
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
`(`) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATEFUND Policy No. }AI83%0ti
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: a 1' / / /Applicant'L�xt�"t
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 6f '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
& 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
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that'[ 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection pposes.
Signature(Owner/Agent)¢'`��4j ""✓" Date
9 a�r
�- BUILDING PERMIT PERMTli
DATE VXUATION LOT �• TRACT
JOB SITE
APN
ADDRESS 144iRGIRVIVA i 111. D10G. 4 t
OWNER
CONTRACTOR/DESIGNER/EN (NEER
.x'l:�L:4, �.�:�;
7Cf�3+.��a"•sL �:C�'l�' C`•Cf. I
46) 20 CAIROUN
W."MAQUPS WA 91802.7
YOD.101 CA 92201
(760)347-31566 Csidt 221
USE OF
(PJER{�MII �T�4y
Iei`P9d�'.3 AL LY ff..l,.tlttllsXfl».TR-T.) t~'E1A)CREL t..i T T EM 510143 {'POM) I.AIP.SF-13
' VALU:F1tMYN �4 0 0, N LS
EL011TRICALMt 101-000-420-000
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RECEIPT
DATEBY
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f� , I F
D FIN E
INSPECTOR
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
t k.
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
F"sumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring - .v
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles -
G. F.I.
Smoke Detectors
Temp. Use of Power
Final /_ _ Q _
Utility Notice (Perm)
COMMENTS:
I PERLA J CONTRACTORS LIC.# 131J5INE55 NAME: Todd LarSen'o GOLF CA125
S��I�T ®' INC WORK , C45,CO C61
• WORKMANS GOMP # CUSTOMER NAME: Todd Larsen
46-120 CALHOUN STREET 1424837-99
INDIO, CA 92201 MAIL ADDRE55 :
(760) 347-3566 CITY LICENSE #
FAX (7050),347-0545 a15 JOB LOCATION:
14"
17;;F1
Lroi OF LA QUINTA
5PECIFICATION5: BUILDING & SAFETY DEPT.
14 " Illuminated Channel Letters APPROVE®
Plex Face: P>lack/White FOR CONSTRUCTION
Returns: Black
Trim -cap: Gold I DATE 9-14401 BY Zed,, —
Transformers to be remotely mounted e in acia rec�uir�-� -
Power to be by others
Lettering to be mounted flush to wall, center on facia ba
a�
a
{ DATE: 1- -2.001
I DRAWN BY
ALBERT TORRES
PHONE NUMBER
i FAX NUMBER
DESCRIPTION OF WORK:
This Is an original unpublished drawing,
crested by IMPERIAL SIGN. It Is submitted
for your personal use In connection with a
project being planned for you by IMPERIAL
SIGN. It Is not to be shown to anyone out.
side your organization, nor Is It to be repro.
duced, copied or exhibited in any fashion.
�jL Lrs?r,-V
OOLF CARS
- 1
26.48 oq. -Ft. APPROVED BY COMMUNITY DEVELOPMENT DEPT
BY -- W r? . DATE o
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