0302-086 (ELEC)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
04 W Professionals Code, and my License is in full force and effect.
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:3M License # Lic. Class Exp. Date
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cZ ti �0'ate ! , !� Signature of Contractor • , ;
_J0 f OWNER -BUILDER DECLARATION
aUJI I hereby affirm under penalty of perjury that I am exempt from the Contractor's
N 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. 704.4, Business & Professionals
Code).
C () I am exempt under Section. , B&P.C. for this reason
LO
N Date Signature of Owner
ON
0- Z WORKER'S COMPENSATION DECLARATION
o1 hereby affirm under penalty of perjury one of the following declarations:
LO O () 1 have and will maintain a certificate of consent to self -insure for workers'
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LL compensation; as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit.is issued.
m Q I have and Will maintain workers' compensation insurance, as required by
p Q Section 3700 of the Labor Code, for the performance of the work for which this
Il rn H- permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier Policy No.
cb t A'i'k: i»'tlPO 1„ 3SF 10-OIIA
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J(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
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subject to the workers' compensation provisior�s.of Section 37 0 of the Labor
odel sh11 fort#iy{ith complyti� diose Yls, __aate:) '�r����� Applicant'arning: Failure to secure Workers' Compensation coverage is unlawful "and
hall subject an employer to criminal penalties and civil fines up to $100,000, in
dition to the cost of compensation, damages as provided for in Section 3706
f the Labor Code, interest and attorney's fees.
MPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold .harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work .is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct: I agree to comply with all City, and State laws relating to the building
nnstruction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for.inspection purposes.
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Signature (Owner/Aggnte-'^4 -" ' Date'•
BUILDING PERMIT PERMIT#
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DATE _ i �� VALUNTIQN LOT- ". TRACT
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JOB SITE
APN
ADDRESS � •kil'�:1. 7������� �.R.$lRlV�E
OWNER
CONTRACTOR / DESIGNER / EN (NEER
LUCAS r,:r';F.:�3•MAJ_ t'O)MW'�'� G L(3.R)*?.
S. R, BMW CC3iRP db aPOWI:: R. PI XIS
1 t 1 ii f?LT,rs11..".1 RF1.'a
T"M 1.4i :P'.I?9 XUB 11A.0'VD
lEWPC 14tT BRACH CA 1,92660
CA :+'1571
USE OF PERMIT
ELYC'.Ma'.w.KL.
ONE 100 AMP POV ER 1140,11,LY- WITH TWO 100AMP P SUH-PtJLF a
"+!'Ai.,tFA'1ION "'.W,00 Lam;
ITRUM FIRE SUNM. 1 Y
F,LtC'1141CAJ, l KP, 101-100-420.000 $4$,00
"FEB t2003
CITY OF LA QUINTA
FINANCE DEPT.
SUB -TOT)Ul CON M, T1 M -1107M MD TITJkW ('31C. CK
T43.00
111MAY, P&MIT PIKE'S DUE NOW
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RECEIPT
DATEl r
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DATE FINALED
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INSPECTO
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 i
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party'Wali Firewall
Exterior Lath
Drywall - Int. Lath
_ r
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
B nd. 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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
.K.
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)
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