0312-226 (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 1363iness,znd
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
,,,.13206/4 C45 / 021281V
at� 6�? ?d1y8ignature of Contractor
OWNER -BUILDER DECLAMTION--
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 employers 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&RC. 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:
Cartier .5. Policy TiNFJ ` Policy No. 4D4pit6s"'tf03
(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
worker's' compensation laws of California, and agree that if I should become
subjecttothe workers' compensatioA provisions of•Section 3700 of"the Labor
" ; )atie: .shall- , lith comply with chose pro '77 ✓Dade: �• + • Applicant J
Warning: Failure to secure Workers CoT4�nsation 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 Sectio_ n 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.
mployees.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
cons ction, and hereby authorize representatives of this City to enter upon
t above-mentioned property for inspection purposes.
Signature (Owner/Agent)R/r0 Date h `R•-
`_/ .
BUILDING "PERMIT FERMITJf
0312-x.26
DATE VALUATION pig!�9p , LOT TRACT
.ADDRESS �JOBSITEY295MG.RWAY,11.1
APN I
Y'
OWNER
CONTRACTOR [DESIGNER / EN (NEER
. ➢v1�>r�4.A Ate. '. ; . • ' .
�1�R. Ta�;�li �1'U°N8
PaCATUNM CA
MCIC:T A, CA 95201
.(209)94S-1113 C. ilf
'
USE OF PERMIT
ELEf":t i CAL
51►�'t�,?J la.LOJI:;lY�t•�'Yfla E:NAl"tY�tE"L1.t� C'I'�It StCrN" 1��P S,r1.03.141 ��N):i - - •
PLANS CR`'li°-STAMPED91b°ITHCDD APP3tt3'1(ALWVBA:tfFRI2001CDC, u
.'41.s JIUA'TION 14
XLECTRIC L FE Y1
06 ctut
,;cltYOF
CEpEPT.
-TOTAL : y,. Yt `i7 ON AND PLAN CHECK
$103.00
.CO
'13 PZ -PAX ? .`
O,OLD • • '
TOTALP _V-2mgT IMES DUE NOW
RECEIPT
DATE
BY�
DATEFI ALED
INSP TOR
i ",1�,. K/,>
Z
I
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 Wail 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
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
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: