0110-049 (ELEC)LICENSED CONTRACTOR DECLARATION
I herebyaffirm under penalty of perjury that 1 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
VDate � " i� Signature.of Contractor .,.Ie
OWNER -BUILDER �DECL"ARATION
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, willAo 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. -
( ) 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 WOWT 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 agr��,e that if I should become t
subject to the workers' compensation provisio 8j'Section 3700 of the Labor•a -
Code, all f rt with comply with those pr issidh °
Dat : Applicant w''�_O
arning: Failure to secure Workers' COW41Vensation coverage is unlawful and
shall subject an employer to:,crmmal 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.
i 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 cessatiori.of work for 180 days will subject permit to cancellation.
:1 ce , if. ihata have,read this application and state that the above information is
correct.:t:agree"to comply with all City, and State laws relating to the building
construction, -'and hereby authorize re�vesentatives of this City to enter upon
the above=mentioned property for i,77,7
nu oses.
Signature (Owner/Agent)�r�
BUILDING PERMIT PERMIT#
r
DATE VALUATION _ LOTTRACT
JOB SITE �-^ "^cp—�"`
APN
ADDRESS ;E� t9su�F:�uif
OWNER
CONTRACTOR/DESIGNER/EN INEER
CTIT tib'Lt9..QC;l1RYA.T IF'�'.fµi;ti?MAAT
E'DWM C3E0RX339 WME
X16815 U-3.01MOM Dye
1A QTYN.CA CA 92253
L. (,dUMA CA 9W:11 3
(3C.dd!"172^1isCi 2851
USE OF PERMIT
ELTIC
Y;WORADIF Cf..1.C°a? PUCAF, P9f.Y If L FROM.125 AMP TO 200.A:.MP
VALVA,THYN l's
-000-420-NO $.9`R 10
OCT 04 2001
CITY OF LA QiJINTA
Fit t4 tC9 pWPT-
SU8.•1aM CCiMMUCT1,09 ARD PLAN 03'"E::CK
$317.50
T011 ,111M ( 'MES ]CSV: NO
$769
RECEIPT
DATE /
BY
DATE FINALED
INSPECTOR
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 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) O- -8- - 5T