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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