0403-161 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMRN
co I hereby affirm under penalty of perjury that I am licensed under provisions of
H Chapter 9 (commencingwith Section 7000)of Division 3 of the Business and 0403-161
ap DATE VALUATION LOT TRACT
N co Professionals Code,and my License is in full force and effect. S.00 B-15
o D M License# Lic.Class Exp.Date JOB SITE APN
W r_ ', A65ki I', //{ 01'31t2( ADDRESS 50 622 SANTA ROSA PLAZA N.
pc I /-- ' ' !'i k / OWNER CONTRACTOR/DESIGNER/ENGINEER
o Z /bate/i '/ '$L- Signature of Contractor
0 NI di
N. OWNER-BUILDER DECLARATION SANTA ROSAPLAY.A,LIJ2(C)APIBROWN) OWNER-IADUDEN
Ill W r I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.O,BOX 1503
H a 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 ( ) • t'L'Ld!
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 171.LE�C`I,RICAI
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ADDITIONAL Lr1:PCTRICAL METM?
co () I am exempt under Section B&P.C.for this reason
in
N Date Signature of Owner
ON
a)d Z WORKER'S COMPENSATION DECLARATION
o ¢ I hereby affirm under penalty of perjury one of the following declarations:
to H O ( ) I have and will maintain a certificate of consent to self-insure for workers'
X W 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 O ( ) I have and will maintain workers'compensation insurance,as required by
O O Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn I— permit is issued. My workers' compensation insurance carrier & policy no.are:
v D �"ier COMMERCEct S[Al9' Policy No. WC9492S73 ESTIMATED COST OF CONSTRUCTION 0,t o
oo
O PPtiRNTIT nit SUMMARY
(This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL PER 101 4)O0-4 20.000 t:13.!A
( ) 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 4 should become
a subject to the workers'compensation provisions' eotion''3700 of the Labor
Code,Lsh I o with comply/with.tllose provisio p.
Date:, s- Applidant 1�_ Ci, / I? der``Warning: ilure 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
airapplication.
1.Each person upon whose behalf this application is made&each person at SUB-TOTAL CONSTRUCTION AND PLAN CHECK $33.30
whose request and for whose benefit work is performed under or pursuant to LESS PRfi•PAII711%tiF.4 YO tt
t* any permit issued as a result of this applicaton agrees to,&shall, indemnify
& 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 1 1 U..RI•�?MCT""MS DUE NOWS33.50
work is not commenced within 180 days from date of issuance of such D
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 is
Si
MAR
D 1,y 2004
correct. I agree to comply with all City,and State laws relatingto the building1'IMI� /
construction, and hereby authorize representatives of this City to enter up
the above mentioned property for inspeesion purposes. 1C DAT FINALED INSP c
/ REcEI
DEFT•Signature (Owner/Agent)_ I / / . - Dar ��'' �• 7•o f�
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
; Set Backs Underground Ducts L
i Forms 8 Footings Ducts L
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 ,J
Utility Notice(Perm) 6 •��O l