9804-058 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT# CONTROL#
co hereby affirm under penalty of perjury that I am licensed under provisions of 404114-lt.SX
I- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE NMI;
VALUATION LOT TRACT
t w Professionals Code,and my License is in full force and effect. 41 Al. )fti a2S1i.IfU 7 O 4
co License# Lic.Class Exp.Date JOB SITE
ti r c0061 i 1. 0'30/98 ADDRESS �225 1/2 DORM STREET
APN
dZ ti pate �t Signature of Contractor r OWNER CONTRACTORIDESIGNERIENGINEER
co O h
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OWNER-BUILDER DECLARATION RJ !RAMS ilk' IU'1'INVI , :'MEN S, f:4'
LU W I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.0 BOX 810 1-i2i I. UNIV.ERS!TV DRIVE
co License Law for the following reason: LA(PINTA 1'A 4-022s3 PH0ENIX AZ X50 t•i
Z_ ( ) I, as owner of the property, or my employees with wages as their sole I6021757-I(14-i 1'RI,t$ 1'.3'10
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals I La.: '
Code). s 4
co I u
() I am exempt under Section , B&P.C.for this reason ICMPUgAR\' t ►Lk- Nk tt+U AMP METER.i'uLL: ,c\1 Date Signature of Owner
OO)
a Z
O WORKER'S COMPENSATION DECLARATION PAID
¢ cc I hereby affirm under penalty of perjury one of the following declarations:
r I— p O I have and will maintain a certificate of consent to self-insure for workers' v ALUri T LO i 7w,(ii)I-',
x W u- compensation, as provided for by Section 3700 of the Labor Code, for the V Iw APR O $ 199$
m J Q performance of the work for which this permit is issued.
Q U (y) I have and will maintain workers'compensation insurance,as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this OF LA QUINTA
la Z permit is issued. My workers' compensation insurance carrier & policy no. are: 4
Carrier Policy No. ,
N- 0 :;rn'n. RIND <,- 123c1 ESTIMATED COST OF(J1NSTRI/CTION 251.0t1
GJ (This section need not be completed if the permit valuation is for$100.00 or less). PERM FEE SUMMARY
O I certify that in the performance of the work for which this permit is issued, ELECTRICAL RICAI,FEE 101-000-420 0 01) lif.tiff
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 r
/
1subject to the workers' compensation provisions of Section 3700 of the Labor
96de,I shall forthwith comply with those provisions.
pate: r .'l' Applicant ti.ti v, f
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
csaddition 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
irfor 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
'':48.4k any permit issued as a result of this applicaton agrees to, &shall, indemnify `.l iT =1'1 1i'A!,(`t1N%'T1 l k"T'It 1N AND PT..AN +'LIT~'{`l Sul(1{L
& 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 LESS L R.L Prt1L! FEES $(3 tuI
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. TOTAL P 'KMI I'V'Ic' mil.:NOW w341.1111
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 t ;�
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) Date
•
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 r
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
1117 Equipment Location
Underground Electric
Underground Plbg.Test
Final Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines Heater Final
Water Piping Plumbing Final
PlumbingTopOut
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 Wring
Low Voltage Wiring
Fixtures
Main Service
SubPanels t'_/ d-a 7
Exterior Receptacles
GF.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)