0403-164 (ELEC) LICENSED CONTRACTOR DECLARATION y
� I hereby affirm under penalty of perjury that I am licensed under provisions of
BUILDING PERMIT PERMIT#
I— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT 0013-1� TRACT
c� w Professionals Code,and my License is in full force and effect. , 5.00 Pr]2
p D r7 License# Lic.Class Exp.Date
] JOB SITE APN
1` illa' n 583ra76 B ,011t311� ADDRESS MI-652 SANfA ROSA PLAZA - ..
. o Z n ,.,.Date-/Y? ,.` -Signature of ContraEtor ( L- 1 ! L t� (i OWNER CONTRACTOR/DESIGNER/ENGINEER
J U m OWNER-BUILDER DECLARATION SANTA ROSA PLAZA,LLC(DAN BROWN) OWNER- BUILDER
W W ^ I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.O.BOX 1503
~ co License Law for the following reason: LA QUIN-TA CA 92253
Z_ ( ) I, as owner of the property, or my employees with wages as their sole ( ) - CL;L.h
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).
0 () I am exempt under Section , B&P.C.for this reason ADDITIONAL ELECTRICAL METER
in
N Date Signature of Owner
0 C
O)
d Z WORKER'S COMPENSATION DECLARATION
0 Q cc I hereby affirm under penalty of perjury one of the following declarations:
Lri r I— 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 - performance of the work for which this permit is issued.
Q (3 ( ) I have and will maintain workers'compensation insurance,as required by
D U 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 Cartier COMMERCE&INDUS Policy No. WC9692fl3 RSIIMATF.O COST OF CONSTRUCTION 0.00
cos
0 PI RI ITT FRE SUMMARY
Q (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEE 10)-000-420-000 $33,50
( ) 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
la
subject to the workers' compensation provisions of Section 3709 of the Labor
Code, I�b II fo hwith comp y with those revisions. .__ il-
Date: / - Pie / . .��
Warning: to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to$100,000,in
l 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
irfor a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made&each person at tftJg_TC1TA[.CONSTRUCTION AND PLAN t'IiFf'ut $ 3.SQ
whose request and for whose benefit work is performed under or pursuant to LE9a^ PRE-PAID FF6,G 33$0.50
ics
any permit issued as a result of this applicaton agrees to, &shall, indemnify /700
& 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 D P(ri, ,PRRMIT P F.KS Dux NOW h�3,50
work is not commenced within 180 days from date of issuance of such
tpermit, or cessation of work for 180 days will subject permit to cancellation. MAR 17 2004 J
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building CITY OF LA QUINTA
construction, and hereby authorize representatives of this City to enter upon FINANCE DEPT.
the above-mentioned property for inspectipn purposes/
JJ RECEIPT DATE BV DATE FIN LED INSPEC OR
Signature (Owner/Agenl) < L l`r, 1" Dat9/> to• I- 0V 7
INSPECTION RECORD
OPERATION DATE I INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms 8 Footings Ducts
Slab Grade Return Air
l Steel Combustion Air
i 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
PlumbingTopOut
� 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
Fodures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)