0008-442 (ELEC)LICENSED CONTRACTOR DECLARATION
�I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
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Professionals Code, and my License is in full force and effect.
�; =) <h License # Lic. Class Exp. Date
►` fLLJ Y ti 674074 13 � 07/31/2(
CS Z ti DateG� Signature of Contractor"—.—
(D 0
ontractor"—(DO
r- U CD OWNER -BUILDER DECLARATION
W WID_ I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
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).
( ) I, as owner of the property; am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
M O I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O�
Q WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
HO () 1 have and will maintain a certificate of consent to self -insure for workers'
K W �= compensation, as provided for by Section 3700 of the Labor Code, for the
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performance of the work for which this permit is issued.
n Q U ( ) I have and will maintain workers' compensation insurance, as required by
j Q Section 3700 of the Labor Code, for the performance of the work for which this
LID i 0)H: permit is. issued. My workers' compensation insurance carrier & policy no. are:
`• zNo.
ob Camer STATE 1<U12D Policyf14tS.U00r°i3R
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J (This section need not be completed f 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 at if I should become
3 subject to the workers' compensatio pr wsx�ris of S tion 3700 01 -the Labor
Code, I�halj�orthwith comply with thoserovisions.
Date: Ll �� F , Applicant--! _
Warning: Failure to secure Workers' Compensation coverage is , nlawful 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
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
dao & 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 I 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 prop ction urp es.
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Signature (Owner/Age t^) ! Dated
BUILDING PERMIT
PERMIT#
DATE VALUATION LOTS
TRACT
JOB SITE �. `}'�' (f/^.
ADDRESS 44,w,� CASC'.AT)A. MC'.,LTf
APN
-
OWNER
CONTRACTOR / DESIGNER / EN (NEER
'TC) mn r 1?l✓'V U)PW-'NT
STARKS Col -(S (iCiTCT1014
.PO BOX 17) E
79.-195 RAMC) 01,A p111N°l'A'1Xt
LA QUINA CA 92253
]A Qt.rtN I'A, CA 92253
(7600,'71.1941 CRIJI 2996
USE OF PERMIT
(1)100 AMP METER PEC711�.,5'I'.AL
VALUATION
300,00 LS
ESTDWA1'.ls3) COST"
OF C010P I7f2-111VK C)Tl
SM(g)
PERIMT FEE SiJNBCARY
ELF,CTR)C.A1,PkDb3TAL 101-000-420-000
MIMI
SQm-,roTAL vowir:[1ZL1C nom AND Yat m (:?swot
$33.50
L1*S3 PRE -PAIL) FEES
$0.00
TOTAL 11"Mii' TIN S )AT HOW
$3.)-su
RECEIPT
DATE
I BY ,
DATE FINALED
INSPECTOR
ir�s�FcTi�r� REc��:n
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BWLLDWG APPROVALS
MECHAN4 CAL. 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.Q.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
B LOCKWAL L APPROVALS
POOILS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PILUMB� NG APPROVALS
Gas Test
Electric Final
Waste Lines,
Heater Final
Water Pipind
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pan§
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer. Conn .. tion
Encapsulation
Gas Piping''
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECT=AIL 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)
COMMENTS:
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