0403-006 (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=1ti _ Exp. Date
15.90 C3 �_r7f3]!?(
Date ` t f �"` 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).
( ) 1, 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.
(�,j 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:
Cartier 9TATEF014' Policy No. lMol f•Aa
(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,•piovisions,of Section 3700 of the Labor
Code,l shall forthwith comply with,those provisions -4A^
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.alkCity, 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) �ti� -- °'"" Date'
aV.9
ILDING PERMIT PERMITk
DATE v VALUATION LOT TRACT
JOB SITE
ADDRESS
APN .
OWNER Y
CONTRACTOR / DESIGNER / EN &NEER
LQ 1WV&T3V.%31hTT PAR.IW
_ M, &MUM'P.fCM itdC
:4940 P)MI E M E& ,
IA QIM4-,A CA, 92253
CA 92509
(909361-3234. M 3518
USE OF PERMIT
I tJ.I.i.dTEt9Jid.A7 TED CAD JNIR7 31 QX,;HAN. C M!0 i�'C70:DKH W�ild, Pirr
APPROV'E SA 0 2004.15%
VALUATION 2000.09 IX
3
EY1CB t 71FI) COST OF CC3NWIRO ;ON
21MAI),00 .
FFM= TARM 913TARY
M- FIC RIC'AJ:, FEE 101-000-420.000 $30,00
�4R 012004
CITY OF
cmia rr- DEPT..
M
SUB -TCiM C01 M"RUCr MON AND RAN CIVACK
$30.00 .
LRI.O5 PRE -RAM Isms
$0,00
PKEMT FEES DIT141 NOW
330.00
RECEIPT
DATE �, _ /
BY
DAT �A✓✓✓�D
INSPEC O x '
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.
Fireplace P.L. Grills
Fireplace T.O. Fans & Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drvwall - IM. Lath
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
isle Lines
Heater Final
ater Piping
Plumbing Final
,Ilumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
I Low
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Notice
COMMENTS: