0403-165 (ELEC) LS
LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
co I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATB, ,, i VALUATION LOT (k(113-1t6 TRACT
PI Professionals Code,and my License is in full force and effect. ,.5:,a B-I 1
o M CO License# Lic.Class Exp.Date
I\ 0 U) JOB SITE APN
� ^ 5 4 G A / --1— ,411/31/2( ADDRESS SO-662 SAN1'A RiiS � 3'f. 7,A
oZO Date— Signature of Contrdcto( I (_ / ,�, ,''` OWNER CONTRACTOR/DESIGNER/ENGINEER
N. v ago OWNER-BUILDER DECLARATION SANPA ROSA IPI.A7.A,LL.C(DPN BROWN) OWNER . BUILDER
re
W w I hereby affirm under penalty of perjury that I am exempt from the Contractor's PO,BOX 1 S03
~ u) License Law for the following reason: LA QUDITA CA 92253
Z ( ) I, as owner of the property, or my employees with wages as their sole ( ) - cat if
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
to construct the project (Sec. 7044, Business & Professionals
Code).
C) () I am exempt under Section , B&P.C.for this reason ADDITIONAL ELECTRICAL METER
O CM Date Signature of Owner
CM
CI)a Z WORKER'S COMPENSATION DECLARATION
o Q I hereby affirm under penalty of perjury one of the following declarations:
r F O ( ) I have and will maintain a certificate of consent to self-insure for workers'
X W LLL compensation, as provided for by Section 3700 of the Labor Code, for the
0 - Q performance of the work for which this permit is issued.
Q CD ( ) I have and will maintain workers'compensation insurance,as required by
O U c Section 3700 of the Labor Code, for the performance of the work for which this
Il Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier
co 5 COMMERCF&INDUS' Policy No. WC9692819 ESTIMATED COST OF CONSTRUCTION 0.0i0
I.- O PERMIT Fly:SiUM&LARY
5 (This.section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL PEP 101.000•420-000 $33.50
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
3 subject to the orkers'corr�1 ensa)ion provisions oL$ection 700 of the Labor
Code rt th con�ly wi lF)ose rovi3ions/
Dates J Appll n [ �l' X'?' C
Warning allure 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 •
irrfor 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
whose request and for whose benefit work is performed under or pursuant to A 148'PRUCfION AND PLAN Cl/ECK $33.`_•0
any permit issued as a result of this applicator agrees to,&shall, indemnify D N �'1 D i i?99 PRE-PAID FEES SO 0?
t
& hold harmless the City of to Quinta, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void if i' I".SAI,PERMIP}TES DUE NOW $37,50
work is not commenced within 180 days from date of issuance of such MAR 17 2004
permit, or cessation of work for 180 days will subject permit to cancellation. -
I certify that I have read this application and state that the above information is CITY OF LA QUINTA
correct. I agree to comply with all City, and State laws relating to the building FINANCE DEPT.
construction, and hereby authorize representat'jes of this City to enter u n
the above-mentioned property for ipspe jrtlo�a-p /pose$.
i / / `�V`, RECEIPT DATE-. . ALED INSPEC OR
Signature (Owner/Agent) /1 / - L �'r Date" 0 e5i
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
ISet 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&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) a.2-J-O `e— N3-7