9909-058 (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 Signature of Contractor
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.
( r) 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' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: Z 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
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 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 property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE ,der4<9il p 3'§.,, VALUATION LOT TRACT
JOB SITE I APN
ADDRESS
OWNER CONTRACTOR / DESIGNER / ENGINEER
!.A {?f ttNTA CA 921 1 ('r'4l1-)ii)3)tr\!. CA 0.1-134
USE OF PERMIT
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RECEIPT DATE BY DATE FINALED JINSPECTOR
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RECEIV lam,01 lJr" { u G i.,'915,
LOAD CALC U LATI ON
PETER DYER RESIDENCE
48800 SAN ISIDRO
LA QUINTA, CA
MAIN SERVICE
LIGHTING LOAD 4,119 SQ FT AT 3 VA/SQ FT,....,.,,,,, 12,357
A
DISHWASHERS 2 AT 1,200 VA EACH
OVEN 2,400
1 AT 8,200 VA EACH,,,,,,,,,,,,,,,,,,,,,,,, 8,200
WARMER 1 AT 1,000 VA EACH,,,,,,,,,,,,,,,,,,,
MICROWAVE 2 AT 1,000 VA EACH,,,,,,,,,,,,,,,,,,,,......11000
DISPOSAL 1 AT 920 VA EACH,,,,,,,,,,, ......' 2,000
920
ICE MAKER 1 AT 1,200 VA EACH...,,,.,,,,,,,,,,,,,,,, 1,200
LAUNDRY CIRCUIT 1 AT 1,500 VA EACH.....,' :.................... 1,500
JACUZZI 1 AT 1,176 VA EACH,,,,,,,,,,,,,,;,,,,,,,,;,,, 1,176
POOL EQUIPMENT 1 AT 6,000 VA EACH,,,,,,,,,,,,,,,,,,,,,,,,,,,61000
YARD LIGHT CIRCUITS 2 AT 1,500 VA EACH„ ;,,,,,................... '3,000
TOTAL LOAD 39,753
FIRST 10 KVA AT 100%,,,,,,,,,,; 10,000
BALANCE AT 40%....,,,. 11,901
A/C UNIT 1 AT 2,300 VA EACH........ , . '2'300
A/C UNIT 1 AT 6,900 VA EACH,.-. , , , , , , 61900
A/C UNITS 2 AT 9,200 VA EACH, . , . , , , , 18,400
FORCED AIR UNITS 4 AT 800 VA EACH,.,..,,,,, 3,200
FUTURE 1 AT 6,000 VA EACH, . , . , , , , , 6,000
TOTAL LOAD 58,701
58,701/240 = 245 AMPS
INSTALL 400 AMP MAIN SERVICE
F
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
.FOR CONSTRUC7'JON
DATE �kl?IBy