0403-163 (ELEC) LICENSED CONTRACTOR DECLARATION -''
(.0 I hereby affirm under penalty of perjury that I am licensed under provisions of
BUILDING PERMIT PERMIT#
WI Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VltLUATION LOT 040:4 16.4 TRACT
I Professionals Code,and my License is in full force and effect. S rb'I I;
^O D co License# Lic.Class Exp.Date JOB SITE
APN
�5 +4C�1d L+ %—HL 31i2r ADDRESS Mt,F„ap SANTA ROSA.PLAZA
oN- Z Date 7/7/1 'J Signature of Contractor , ✓ ,- ( j / r OWNER CONTRACTOR/DESIGNER/ENGINEER
Co _
N-
I-- U G OWNER-BUILDER DECLARATION SANTA ROSA PLAZA,ILA2(UAN BROWN) OWNER-BUILDER
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's P O. BOX 150;
co License Law for the following reason: LA QIJINTA CA 92253
Z ( ) I, as owner of the property, or my employees with wages as their sole ( ) . CLUmti
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 ELECTRICAL contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt under Section , B&P.C.for this reason AULIITIONAI IfLC+C1TRICAL MRTF.R
O N Date Signature of Owner
Cr)E C WORKER'S COMPENSATION DECLARATION
in Q S I hereby affirm under penalty of perjury one of the following declarations:
r H O ( ) 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
0O - Q performance of the work for which this permit is issued.
Q (.,) ( ) I have and will maintain workers'compensation insurance,as required
0 a.- Section 3700 of the Labor Code, for the performance of the work for which this
O s
d v Z permit is issued. My workers' compensation insurance carrier & policy no. are:
co Z Carrier COMMERCK&INDUB' Policy No. WC9692873 EWTIMAT.KD COST OF CONSTRUCTION 0.00
N- 0 PERMIT FEE SUMMARY
5 (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEE 101.000-420-000 S33.10
( ) 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 Califomia, and agree that if I should become
3 subject to the orke.rs' compe sation provisions of_Section 37 0 of the Labor
Code,1-s111 ith complywit¢'those provisions. 1;/ .`,7O
Date.l pplica'ht 1_ i • ..
Warning: ailure 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
iirapplication.
1.Each person upon whose behalf this application is made&each person at I CONSTRUCTION ANDT LAN CHECK33
whose request and for whose benefit work is performed under or pursuant to"' I I r
any permit issued as a result of this applicator agrees to,&shall, indemnity aI LEIS PRE-PAID FF <Il r;
lt & 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 4 '('C']'I'AI,I`F'RMIT l �POENOW3._,5•'.0
Y work is not commenced within 180 days from date of issuance of such MAR 17 200
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 CI FINANCE DEPT.F LA A
J
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 inspection purposes. -
� r,.. RECEIPT DATE aY DATE� FINALED INSPECTOR
Signature (Owner/Agent)' ( / L 'et' Date = `•'/`! - 7 '27.o V 4z
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION r-- DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs r 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
Utility Notice(Perm) .L,,27-p y! �7