0108-293 (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
. __Idt r I A .'f
Dat�dSignature of Contractof
�mbWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that,l 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
( ) 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, , '2 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 Policy No.
(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' compen spti a6QkPro�yisfions of Secti n 3700 of the Labor
Code;ill shall forthwith comply wifh,,tF!4ee pr8"yjsjons'�l%
Warning: Failure to secure Workers'ECompensation�boverage -is unlawfUland
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 df 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 m
whose request and for whose benefit .work is performed er or pu1AXt to
any permit issued as a result of this applicaton agrees , s a:nenl y& hold harmless the City of La Quinta, its officers, ag s nde2. Any permit issued as a result of this application bec a nu 1work is not commenced within 180 days from date f i uanuch
permit, or cessation of work for 180 days will subject prmi QU
I certify that I have read this application and state that the[above inf�ftf�tlbB6sDEl
correct. I agree to comply with„all City, and State laws::relating to the building
construction, and hereby avtf &izejrepresentatives of :this City to enter upon
the above-mentioned prollerty;for(Inspection purposes.
7
Signature (Owner,—- nt "r” � ,�>r � `r+ • a ^�'� - Dateit,"r, 1""`2 `)
BUILDING PERMIT PERMIT#
DATE VALUATION LOT TRACT
1
JOB SITE - M
APN
ADDRESS
OWNER
CONTRACTOR'/ DESIGNER / EN 1NEER
E , L?"T1l i?f � u "' iC7 : WWOMf S SOl: IT11€
1, 02 VORZESS 114177 ctba 02 WGQ:E?LWZ0 HOWT,
d300;C.:tIMMI 103
CA 92051
R:iVER EME .(,'A 92501
(909)788.0740. C&O {,
USE OF PERMIT
f
CQI?r iAERCLIAL "
���a��.����°j� ��x������f�r� �:�?1.1.tt�..r���, s��'�. �f•��A Crr;��ii��.�re;���. fAtz�•I�
I
OL'' ^' Hf,IMW-KS.IUG/l: • JS.)tJ•VYJ.��IG:�,'r .Y.�C.::°�ii7 t
.. .f..:- �L.'
C010 t4ACT AMOUNT %.- 06tt.60 U%
HWY
CONOTRUCTION FEE. 101-000-418-000
MECRNWICAL NEI $51,00
3,'.i=`fRICAL V&P, 04.69
STRONQ Mt'i` TO)4 RE • COMM 100 -OW -741 -OW $1.21
ORADIV40 FZZU' 101-000-423-13(y4 $79.0111
DEV1;WPE.C? IP,.6`f'ACT FEE
!kRTI' N P BL1C 1"LACHS • COW 270••000 -445 -CM
O'(YY1,'.%'C9"Y. J� rol1sl%arrQEy AND PLAN MIRCIITY1..
1590.83
.C13S FTA^yJEtv
/a
$0.00
0010 �Z1. '. 'EP DV N47W
? f,
NTA
T.
'DAT
RECEIPT
BY
DATE FINALE
INSPE R
_U
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings v
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
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)
a
Bin #
City of La Quin- to
Buff(ring ff Safery Division
P.O. Box 1504, 78-495 COO Tampico
La Qidnta, CA 922S3 - (760) 777-7012
Building Permit Application and Tracking Sheet
Pem* #
10(oll-
Project Address: 12, Owner's Name:
A- P. Number Address:YIP-61 0 3
Legal Description: LCity. ST. Zi Ar A:;:, ,
Contractor. Telephone: ,
9
, —79,7—eh(o 1-1;et�zo
Address: Project Description: IJI fM *AfAJ-;r&l
City. ST. Zip:
Telephone: ..........
P State Lic. it: City Lic. N:
4/^ W;I"4
Arch.. Engr.. Designer:
)--5
Address: FO -2/ (Zf—elAcE -Te,4,Po44ay
/
City. ST. Zi A14,
Telephone: ruction
Const Type: V-0 Occupancy:
State Lic. #: Project M -pe (circle one): New Add'n Alter Repair Demo
of Contact Person: �,fely jkv Sq. Ft.: LI) # ries:
(Name
Telephone
Telephone # of Contact Person: Estimate-2dvalue of Project
qolcq7-7f% APPLICANT: DO NOT WRITE BELOW THIS LINE
N
2,.
Submittal
t F/4&V;4
Plan Sets sPlan
Req'd
�
Rec'd
TRACKING
Check submitted
PERMIT FEES
—
Item Amount
2—
Structural CaIcs.
Reviewed. readv for corrections
Plan Check Deposit
A9; L
Called Contact Person
Plans picked up
Plan Check Balance
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
1" Review. ready for correctionslissue
Electrical
Subcontactor List
Called Contact Person
Plumbing
S. N1. 1.
Grading
Grant Deed
Plans picked up
H.O.A. Approval
Plans resubmitted —
-------
IN HOUSE:-
Review. ready for correctiOnSASUe
-
Developer Impact Fee
Planning Approval
Calle d Contact Person
A. 1. P. P.
Pub. Wks. Appr
Date of permit issue
School Fees
N5 6x -m
0/1
01A�c
ALL�
Total Permit Fees
.1.'
City of La Quinta
Developers Project Approval Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. Contact applicant for resolution of conditions preventing or. delaying approval.
Project: Unmanned Cellular Communications Site
78-950 '/z Highway 111 l�
Applicant Contact: Bob Muller/Arthur Hayes, Verizon (909) 788-0740 x 201,204
Application / Circulation Date:
Community Development Department
Christine di Iorio, Planning Manager
Public Works Department
Steve Speer, Senior Engineer
Building and Safety Department
Greg Butler, Building & Safety Manager
Date z�
Date
Date
Date