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 -