0209-149 (ELEC)LICENSED CONTRACTOR DECLARATION
(hereby affirm under penalty of perjury that I am licensed under provision's of, -
Chapter 9 (commencing with Section 7000) of Division 3 of the B6siness,-and,*
Professionals Code, and: -my License, is in full force and effect.
License# Lic. Class Exp. Date
17- C-10
�'te`g 11-(V2 Signature of Contractor kA4,1'!k' ltv Ptl*
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
Licdnse Liw for the foll6wing reason:
1;1as owner of thig property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered f I or
sale (Sec. 7044, Busin e�ss & Professionals Code).
1, as owner of the property, am exclusively contracting with'licensed
contractors to construct. the project (Sec., 7044, Business & Professionals
C6cle).
l,arn exempt under S6ction B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION'
I hereby affirm-^s,`Uxncler 'penalty of perjury one of the following declarations:
I have andl,will maintain a certificate of consent to self -insure for workers'
compensation, .,Jai'g'provided for b - y Section 3700 - of the Labor Code, for the
performance of the worW-.f6rwhich this permit is issued.
-I hav& and will. maintain workers' compensatidn insurance, as required by
Section 3760 of the Labor Code, ,for the performance of the work for which this
permit,is issued. My workers' compensation insurance carrier & policy no. are:
Cairrier, PI LE
.MNITy r,4S Co Policy No. WCOW367-01
(This section need - not be compl4t6d if the permit valuation is for $100.00 or less).
I certify that in th6 performance of the work for which this permit.is issued,
I shall not employ.aoy 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 th e pr VISITh
..,.Date -Z",) - JQ4- 1-9. 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 pu ' rsuant to
any permit issued as a result of this applicaton agrees to, & Shall,= indemnity
& hold harmless the City of La Quinta; its officers, agents and employees.
2. Any permit'issu;d 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 cancellatio6.
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'ehfier upoq'
the above-mentioned property for inspection,purposes.
;e
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'Signature (Owner/Agent) Date Ct
PERMIT#
TERMIT
�112JUJJUPING 14.
,DATE �vALUATION LOT S,i TRACT
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JOB SITE- ;v
ADD4RESS-.Ir;P-.41--%'A,.W,:.MK,Vt Asp()
APN
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OWNER Z ♦
CONTRACTOR DESIGNER I ENGINEER
•
52-4-15' LAI
85q,SO, FSTA WAY'
-.A QUM 7CA, 9' 253 1,
'A CA. 922,33
21.
(760)772�1770 (*.%..L# -4066
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USE OF PERMIT
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A rKRIAUT MIX -Now
SEP -71 9 20102
CITY OF LA QUINTA
FINAN 'T.
RECEIPT
DATE{]
ATEBY
'
DATE FINALED _1INSPECTOR
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
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
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:
'1
S
Final
Utiiity 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)