0403-168 (ELEC) )Y
LICENSED CONTRACTOR DECLARATION PERMRN
CO I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 111-168
F Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE VALUA ON LOT TRACT
.�-W Professionals Code,and my License is in full force and effect. - /� SA0
p M License I Lic.Class Exp.Date
n 0 In / JOB SITE APN
IIr�ILI ^g. Sg44i>;, It -,'_()WI/2( ADDRESS Sit 412 1/2 SANTA ROSA PLAZA
0 Zr-. :ate ^�� • /�� Signature of Contract?). • '_ !.4'r./- OWNER CONTRACTOR/DESIGNER/ENGINEER
m 0 II-
U / OWNER-BUILDER DECLARATION SANTA ROSA PLAZA,1[C(TJAN BROWN) OWNER-1?Ull d)FT
HW r I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.O.BOX 1503 it
co License Law for the following reason: IAQUINTA CA 92253
Z ( ) I, as owner of the property, or my employees with wages as their sole ( ) • 171.11J1
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 FT.RJ'TRTCAI.
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
co () I am exempt under Section ,B&P.C.for this reason 180 AMP METER PEDESTAL. (FOR POOL)
in
w Date Signature of Owner
ON
(3)E Z WORKER'S COMPENSATION DECLARATION
o ¢ cc I hereby affirm under penalty of perjury one of the following declarations:
r F- 0 ( ) I have and will maintain a certificate of consent to self-insure for workers'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
00 -I Q performance of the work for which this permit is issued.
CO Q 0 ( ) I have and will maintain workers'compensation insurance,as required by
L) 0 c Section 3700 of the Labor Code,for the performance of the work for which this
CC try)) I— permit is issued. My workers' compensation insurance carrier& policy no. are:
vco Z any C0MMERCEA.D1DUB' Policy No. WC9h926'Y.r ESTIMATED COST Of CONSTRUCTION OAX'
N- 0 PERMIT WEE SUMMARY
5 (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL.FEE 101-000-420-000 E 4.3.10
( ) 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 Califomla, and agree that if I should become
la subject to he orkers'compensation provisions of Section 3700 of the labor
bode, all f h ith comply with those pprovisions. ;r- /
�DaApplcant ,. /." Z (,f.-7,r-A 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
vsof 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
ir
application.
1.Each person upon whose behalf this application is made&each person at
I ;- 'Opt.CONSTRUCTION AND PLAN CHECK
whose request and for whose benefit work is performed under or pursuant 1 -1 $33.50
�1 any permit issued as a result of this applicaton agrees to,&shall,indemni !;A LESS PRTi•PAIT]I•T,E.9 Y0.0(1
�('� & hold harmless the City of La Quints., its officers, agents and employees.i ,. , '
Q 2.Any permit issued as a result of this application becomes null and void if TOTAL PERMIT PEES DUI'PLOW $S0 00
work is not commenced within 180 days from date of Issuance of suchill MrEll` 17 20011 J
permit,or cessation of work for 180 days will subject permit to cancellatlon.4
I certify that I have read this application and state that the above information is CITY OF LAQUINTA
correct. I agree to comply with all City, and State laws relating to the building 1 FINANCE DEPT.
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
" RECEIPT DATE B • DgEFIN D INSPECT.O3
Signature (Owner/Adent)- Date-~//' ��� b• � �-
i
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
I 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 8 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) 0./Vit