0403-160 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMITS
O I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9(commencingwith Section 7000) of Division 3 of the Business and 11AlY3-1(dJ
P DATE VALUATION LOT TRACT
Co N W Professionals Code,and my License is in full force and effect. $.UO F;•1 G
p m en License 8 Lic.Class Exp.Date
JOB SITE
C n .S1C>-''t, 1>, (11:41!Z( ADDRESS 51.1.(�T'.L SAIH`T'A Rosa T/I,AZA DN
-'Z n Date 7.,7/e , r'%! OWNER CONTRACTOR/DESIGNER/ENGINEER
• o Signature of Contractor
O �
U CI OWNER-BUILDER DECLARATION BANTA ROSA.PLAZA,I.IXXDAN BROWN) OWNER -Pull Mai
HW I hereby affirm under penalty of perjury that I am exempt from the Contractor's P,O. BOX 1503
Tn License Law for the following reason: LA QUINT& OA 9225?
Z ( ) I, as owner of the property, or my employees with wages as their sole ( ) • CESTdt
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professionals Code). usE of PERMS
( ) I, as owner of the property, am exclusively contracting with licensed FLFX'1RJCAl
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
to () I am exempt under Section , B&P.C.for this reason ADDITIONAL I?LEC i'RTCAI,METF.f3
N
O CMDate Signature of Owner
rn
d Q WORKER'S COMPENSATION DECLARATION
o Q tx I hereby affirm under penalty of perjury one of the following declarations:
✓ I— O ( ) I have and will maintain a certificate of consent to self-insure for workers'
x W Liz compensation, as provided for by Section 3700 of the Labor Code, for the
0 LI RIperformance of the work for which this permit is issued.
MI Q U ( ) I have and will maintain workers'compensation insurance,as required by
C) 0 d Section 3700 of the Labor Code, for the performance of the work for which this
Il tag I- permit is issued. My workers' compensation insurance carrier& policy no. are:
co 5 RI
Cartier COMMERCENDU2' Policy No. WC969387 EFIIMA'Tf:T)COST OF COMM,TenON CLOG
N 0 PERMIT FEE SUMMARY
(This section need not be completed if the permit valuation is for$100.00 or less). ELECIRICAI.FEE. 101-000,420-000 5.4:1.SO
( ) 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��ShI fo hwith camplywith those provisions '-1 �I
Dater /� (/ Applicant` ,1 i /fif D
A Warning: ailurre to secure Workers'Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to$100,000,in MAR 1 7 2004
addition to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attomey's fees. CITY OF LA QUiNTA
IMPORTANT Application is hereby made to the Director of Building and Safety FINANCE DEPT.
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 90B-TOTA(,C O11Ji _UCT1ON AND PT_v pj CHECK t33 50
whose request and for whose benefit work is performed under or pursuant to
t any permit issued as a result of this applicaton agrees to,&shall, indemnify EJi3� PRR-PAU I ITE,� V3& 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 'TOTA.L 1''h.'h'11'1TT F EKES DUE NOW 3 till
work is not commenced within 180 days from date of issuance of such
tpermit, 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 for-insp%ction purposes. J� //''/ RECEIPT DATE BY DA�f'NA INSPECTOR
Signature (Owner/Agent) ' ' `� Dale_i��F"�- 513 0 V sr
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 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 I 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 Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm) /3..O le .52