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0403-162 (ELEC) LICENSED CONTRACTOR DECLARATION PERMITS CO I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT DaiI— Chapter 9 (commencingwith Section 7000) of Division 3 of the Business ands IG2 DATE VALUATION LOT TRACT co Professionals Code,and my License is in full force and effect. 1.00 13.1$ o D M License# Lic.Class Exp.Date JOB SITE APN W ^ i t,Sr, B ✓ Ql 311 ADDRESS 50-632 SANTA ROSAPLAZA � Date. /// /- Signature of Contrabtof: ,/ r '.// rr t 6 Z - OWNER CONTR4kCTOR/DESIGNER/ENGINEER CO o hi C~1 g. r OWNER-BUILDER DECLARATION SANTA ROSAPLAZA,L112,(D.AN BROWN) OWNER-BUILDER I— d I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.O PDX 1503 r in License Law for the following reason: LA QUINTA CA 1225:1 Z ( ) I, as owner of the property, or my employees with wages as their sole ( ) - '=lilt` 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 F1FC"17ZICAI contractors to construct the project (Sec. 7044, Business & Professionals Code). 0, () I am exempt under Section , B&P.C.for this reason ADDITIONAL ELECTRICAL METER N Date Signature of Owner O O) . O) d Z WORKER'S COMPENSATION DECLARATION o cc I hereby affirm under penalty of perjury one of the following declarations: r -- 0 ( ) I have and will maintain a certificate of consent to self-insure for workers' x W IL compensation, as provided for by Section 3700 of the Labor Code, for the 0 -I rl performance of the work for which this permit is issued. CO Q () ( ) 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 d la I— permit is issued. My workers' compensation insurance carrier & policy no. are: cb 2 canes COMMERCE&.INDUS. Policy No. WC469E873 ESTIMATED COST OFCONSIRffC'flON f?±Ml N v PERMIT Fit SUMMARY C (This section need not be completed if the permit valuation is for$100.00 or less). El.E.CTRICAL FEE 1 01-0004 20-000 $:(% 50 ( ) 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 action 3700 of the Labor Code, I shall f hwith comply,with those provisions. / / Date: Applicant / / / / �i.�'l A Warning: slur 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 csof 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 whose request and for whose benefit work is performed under or pursua 8UB I.AL CONSTRUC IO.N ANT)PLAN CHECK S?l.50 any permit issued as a result of this applicaton agrees to, &shall, indem` ^ ' LESS P.kfi-PA[U BEES SCAM) hold harmless the City of La Quinta, its officers, agents and employ-: 2.Any permit issued as a result of this application becomes null and voi+ TOTAL PERMIT FEES DUE NOW S33qf) work is not commenced within 180 days from date of issuance of s lI MAR 1 1ry 2004 permit, or cessation of work for 180 days will subject permit to canceliati. I certify that I have read this application and state that the above information CITY OF LA QUINDEPT A correct. I agree to comply with all City, and State laws relating to the buildi _. FINAN construction, and hereby authorize representatives of this City to enter upo the above-mentioned property for inspection pLlrpjises. RECEIPT DATE BY D• E Fl •LED INSPECTOR, Signature (Owner/Agent) . / i ii /r.t'r-.. Date /'//(y- - D INSPECTS" 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.toWrap ---- ---- F.Au - - -- -- - Framing Compressor Insulation Vents - - - Fireplace P.L ---y Grille - - - - -~ Fireplace T.O. Fans&Control Party Well Insulation Condensate Lines Party Wall Firevall Exterior Lath Drywall-Int Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS Step Set Backs _ Electric Bond Footings Main Drain Bond Beam _ Approval to Cover Equwprne"t location Underground Electric �- _Urutergro:md Ptbg Teat Final Gas Piping '-Gas Test PLUMBING APPROVALS Electric Final Waste Wits Heater Final Water Ptpdng Plurrb.n$Final Plumbing Top Out Equipment Enclosure Shower Pans - O K for Finish Plaster Sewed Lateral -- Pool Cover Sewn Connection Encaps,,,atan Gast — l Gas Test Appiances Final COMMENTS: Final --OWN Hobert(Gas) ELECTRICAL APPROVALS Temp Povder Pole - - - ot.md Conduit Ro-_rzr W... •� Low N.orta9e V.sing Futures _Mari Service _Sub Panels Exterw Reoa acacias -- GFt -- Lmwe Deteyors i --`— Temp Use of Power Final Utility Notice(Perm) o yir -