0403-158 (ELEC) LICENSED CONTRACTOR DECLARATION S
co I hereby affirm under penalty of perjury that I am licensed under provisions of
BUILDING PERMIT PERMITI
I- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE vnwnnoN LOT (J4tE i 58 TRACT
N LLu Professionals Code,and my License is in full force and effect. / T.00 11,-I f;
o D co License# Uc.Class Exp.Date /
LO JOB SITE
APN
� W G_ ^ 58465(. B 01I3112t ADDRESS S0.S92 SAN'lA ROSA PLAZA
'' Z n ,.Date I 7 Signature of ContrlOcto[ ,( ( ('�/A. OWNER • CONTRACTOR/DESIGNER/ENGINEER
(O Q
-J jr_ m OWNER-BUILDER DECLARATION SANfAROSAPLAZA,I.Tr(DAN BROWN) OWNFSc- BUILDER
W LU P... I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.O,BOX 1 503
~ CO License Law for the following reason: LA QUINTA CA 92233
Z ( ) I, as owner of the property, or my employees with wages as their sole ( ) .. CBL!$
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 ELECTRICAL
to construct the project (Sec. 7044, Business & Professionals
Code).
o () I am exempt under Section , B&P.C.for this reason AODITIONAL ELECTRICAL METER
OCV N Date Signature of Owner
CId Q WORKER'S COMPENSATION DECLARATION
o Q cc I hereby affirm under penalty of perjury one of the following declarations:
fa.- I— O ( ) I have and will maintain a certificate of consent to self-insure for workers'
x W l compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q O ( ) I have and will maintain workers'compensation insurance,as required by
O 0 c Section 3700 of the Labor Code, for the performance of the work for which this
ccv Z permit is issued. My workers' compensation insurance carrier & policy no. are:
cos
Cart CoMMERCE6tninu8' Policy No. WC9692873 ESTIMATED COST OF CONSTRUCTION O.00
r-- O PERMIT FEE SUMMARY
(This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL.FEE 101-000.420.000 - $33.30
( ) 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
a subject to the workers' compensation provisions of Section 3700 of-the Labor
Code,I s II fo hwi comply with thoseprovrsions. --~
Date- APp�ant .. / // • - Y T .
• Warning: ailure 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
44 application. \
1.Each person upon whose behalf this application is made&each person at b _ (;)T. YgI'1?UCL7ON AND PLAN'CHECK whose request and for whose benefit work is performed under or pursuant to 33 S0
t any permit issued as a result of this applicaton agrees to, &shall, indemnify Loa LESS PRE-PAID FEES '80.t10
& hold harmless the City of La Quinta, its officers, agents and employees.2.Any oid if `1
work is not(commenced within 180 t issued as a result of (days applications fro dates of issuancees null od f such \\P� Q�t�!1�H 1 nT 1,PERMIT FEES DUE NOW $33.5.0
permit,or cessation of work for 180 days will subject permit to cancellation. C��g0£P
G�� r.NG
I certify that I have read this application and state that the above information is Cat"
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 for inspection purposes. -
/' RECEIPT DATE BV DA FIN ED INSP�F R
Signature (Owner/Agent) (( ' '' Dates%!/ •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 i 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 Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines Heater Final
Water Piping Plumbing Final
Plumbing Top Out ` Equipment Enclosure
Shower Pans l 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) 6• (g-p og 7