0301-141 (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. y
License.# Lic. Class Exp. Date '
455990
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.
( ) 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 STATE FUND Policy No'.0200 Z22
(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, andagree that if I should become
subject to the workers' compensation, -provisions o�Section 3700 of the Labor
Code, shall forthwith comply with those provisions
'Date: Z, 21` .: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 of
whose request and for whose benefit work is performed under or pursuant td
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 fon-inspection-purposes. ;
Signature (Owner/Agent) %-' •�� r' •• Date
w')
t?;3`i i ,PEaMIT# ,
�` 1 BUILDING PERMIT
DATE VALUATION LOT 0*30 '-141 TRACT
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JOB SITE�
APN
ADDRESS . �� J sAx i�� Y.
6�-� %� a
OWNER
CONTRACTOR DESIGNER IINyEEEtR
yY,ry T y�
�/EN
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Ar7if�RI.t..crJ,.l d-.J.,t X',2lCTC r.
44-370VILLEYADR
6519- 116 CLUBROAD
C ''31A `Z1ZTI
1 '
USE OF PERMIT
FJA?.G`FRI'CAL M17MTCS; UPGRADE. TO 200 AMP MAIN SERVICK
VA.LVXf 1015 1,204.E l .1"s �Z.,;
•1
,O:�e7 �i�J.�YA.9 d..f� 4���Y�+�{�+' �`��` �el, YA?J.t�d�i.�ltl '`
`•.• • �C16{rcr�F
ELL?CT ruCIA . FE, 9 101-000-42,0-000 b3�,
CYfAL
l„? e41 'M-VAY F—E.Y33
JAN p g 2003 • Yf Ala FEERM :.TMS TWE NOS
CITY OF LA QUINIA
FINANCE DEPT
N J"
RECEIPT
DATE / j
x
B 0 '
UDATEFINALED INSPECTOR
.;
A
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
BoM 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
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) — `
COMMENTS:
CIT -Y OF LA QUINTA SUB -CONTRACTOR LIST
JOB ADDRESS �y-3�(7("(-2460
LL r_TA ,7%2 PERMIT NUMBER OWNER 6�_ ��,r�E Y BUILDER .
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will. result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade /Classification Contractor State Contractor's License- Woikers Comperisation Irsurarice City Business License
Company Name _ Classification License Number Exp. Date Carrier Name Policy,Number Exp. Date License Number Exp. Date
(e.g. A, B, C-8) (xxxxxx) (xx/xx/xx) (e.g. State Fund, CalComp) (Format Varies) (xx/xx/xx) (xxxx) (xx/xx/xx)
EARTHWORK (C-12)
CONCRETE (C-8).
FRAMING: (C-5)
STRUCT.;STEELIC-511..
MASONRY (C-29)
PLUMBING (C-36)<
LATHi::PLASTER (C.=35):`>:'
DRYWALL (C79)
ELECTRIGAILIC.;101'..'.:.::,> 1314 i�EC7`,2, C=EO / ,- 7 5 �r/ 1 S N>
ROOFING IC=39► : :,-
:SHEET METAL'(C43)>:
i.
i
FLOORING'
p
INSULATtON;1.0=21.:
I
SEWAGE':pISP•;.IC:42) <i::
i
PAINTING;;IC 33)::` ::: .
t
CERAMIC:'TILE..(C-541`;:::>r:' h
C .
ABINETS IC:=.6)
FENCING .(C=.13)'.„17--77777 -i
LANDSCAPIN741 G
POOL IC=53)`
CITY OF LA QUINTA SUB -CONTRACTOR LIST_
JOB ADDRESS PERMIT NUMBER OWNER BUILDER
This form shall be posted on the job with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be comnleted by annlirant_ "On FiIP" iS not nn ar rPntahlp racnnnca
Trade / Classification
Contractor -
State Contractor's License .
Workers Com ensation Insurance '
Cit Business License
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date
(xx/xx/xx)
Carrier Name
(e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C-12)
CONCRETE (C-8)
FRAMING (C-5)
STRUCT. STEEL (C-51)
MASONRY (C-29)
PLUMBING (C-36)
LATH, PLASTER (C-35)
DRYWALL (C-9)
HVAC (C-20)
ELECTRICAL (C-10)
ROOFING (C-39)
SHEET METAL (C-43)
FLOORING (C-15)'
GLAZING (C-17)
INSULATION (C-2)
SEWAGE DISP. (C-42)
PAINTING (C-33)
CERAMIC TILE (C-54)
CABINETS (C-6)
FENCING (C-13)
LANDSCAPING (C-27)::.....
POOL (C-53)
CALCULATI N - O FAMILY DWELLING
(NEW
OR EXISTINC�I
R 1. OTHER LOADS - 220-30(B)
General lighting loads - 220-30(b)(2) r.
2�svVA'_ r
sq: ft.x'3 -
V
Small appliance and laundry loads - 220-30(b)(1.)
.
I A
150 VA x 2 circuits =
Special loads - 220=30(b)(3)
G� VA
Dishwasher =/450 VA x circuits `
L.. `Disposal = Zo —Z---
�_ VA x 2
� 50 VA., .
circuitsVA
Compactor = VA x - circuits
.
Water heater = G/9 S t -VA x �' circuits
F.A. V. = fI 5 VA x -.circuits -
i VA
----�-- VA
Pool Equip. = 5l? �VA z _circuits
S,foye =� VA `
----VA
aU VA
x circuits
VA x circuits
oov VA ,
.
V A x circuits
VA •
a U VA •
VA x circuitsjS
D VA
.: .(total)
F120 VA
Applying demand factors - Table -220-30.
R_ First 10,000 VA x.100% - 10,000 VA
. ' Remaining 4�20hA. x 40 % �o_VA
;
•
total ' 67
(total) �' 9VA
l %S(VA
' 2. 4 HEATING OR A/CLOAD - TABLE 2.20-30(1)(2)(3)=
Heating units (3 or less).
r—=VAx6�%
Heating
VA
.
.units• (4 of more) _ VA x 40%
VA
_ A/C unit = 6000 • VA x .'circuits
.k
Heat pump
P P VA x circuits
•,
VA
(largest load) VA VA
4 • TOTAL _V A
a
` 3.- 8000 VA. Nil DERATED FUTURE
f�A
'Single phase service: A = y®
V
- VA /Z' A
_
L 2:qV
' Service amperes req'd
12,?A
Service amperage provided
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