0403-167 (ELEC) NI
LICENSED CONTRACTOR DECLARATION PERMIT#
CO I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
I— Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE yr UATION (O LOT (1403 1�'7 TRACT
coCNI Professionals Code,and my License is in full force and effect. 1/
p m License# Lis.Class Exp.Date
1".-Cr if) / JOB SITE APN
1.W r ^i 64656 7 ,Ol tf l/2( ADDRESS yO-614 InSANFA ROSA PLAZA -
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Z , Date /7/Gf
t- r - Signature of Contractor _ • , ' (
t jJt of%+: OWNER CONTRACTOR!DESIGNER/ENGINEER
(00 � - / '
v1 r OWNER-BUILDER DECLARATION IIANTA ROSA PLAZA,LLC(DAN8)-oWN) OWNER-BTJILDc
FalI hereby affirm under penalty of perjury that I am exempt from the Contractors P.O.BOX 1503
co License Law for the following reason: LA QUINTA CA 92253
Z ( ) I, as owner of the property, or my employees with wages as their sole ( ) , CBIfh
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 �+C'fRTCAL
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
CO () I am exempt under Section , B&P.C.for this reason 100 AMP METER.PEDESTAL(MAP POOL)
in
Q N Date Signature of Owner
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d• Z WORKER'S COMPENSATION DECLARATION
0 Q 2 I hereby affirm under penalty of perjury one of the following declarations:
▪ I— Q ( ) I have and will maintain a certificate of consent to self-insure for workers'
X W I compensation, as provided for by Section 3700 of the Labor Code, for the
Om - Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers'compensation insurance,as required by
Q 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
IZ g3 I-R Z permit is issued. My workers' compensation insurance carrier & policy no. are:
ao O3 Garner COMMERCEEINDUS• Policy No. WC46928T3 ESTIMATE!)COST OF CONSIRUCIION DA0
PERMIT MtiSUMMARY
5 (This.section need not be completed if the permit valuation is for$100.03 or less). ELECTRICAL FEE 10 i-000.42N-000 $33.Si;
( ) 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
3 subject to tI�w rkers'compensation provisions-ot Section 3760 of the Labor
Code,!-pF�IIJ ith comply with those provisions. , ,;
1DateL �// i Applicant ,;
Warning: Efailure 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 attomey'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 j tr 1`I i r
whose request and for whose benefit work is performed under orpursuant to NyTRLIC f1 1N AND PLAN CHECK
q /� • I $33 50
�\ any permit issued as a result of this applicator agrees to,&shall, indemnify U j G�i LEsJ9 PRfi-PAR?kx II_4 ?0.00
r�V�lp & 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 I w 2 1 -I QTAL PK1tMCI'k'F:LrS AlTE NOW °-
work is not commenced within 180 days from date of issuance of such '] MAR 1 / [��4 r,��_�Ai
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 is41 Cl i F LA VUINTA
correct. I agree to comply with all City, and State laws relating to the buildin s 1NANCE DF,PT.
construction, and hereby authorize representatives of this City to enter up
the above-mentioned property for inspection`gurposes., /
r `i, i -� /� RECEIPT DATE BY DATE FINALED INSPE
Signature (Owner/Agent) Dat f Z_c(O `e
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 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 4O V G`i
Utility Notice(Perm)