0403-166 (ELEC) LICENSED CONTRACTOR DECLARATION PERMIT#
(n I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
040I— Chapter 9 (commencingwith Section 7000) of Division 3 of the Business and itd'
ap DATE .. . - VALUATION LOT TRACT
w W Professionals Code,and my License is in full force and effect. l I tOO B.10
o D cr) license# Lic.Class Exp.Date -
JOB SITE r; a to
w n SI14ti56 B / 1131lat ADDRESS 50-672 SANTA ROSA PLAZA APN - -
O rt / g 9r' Il'( ,` /t 7(,6 � OWNER • CONTRACTOR I DESIGNER/ENGINEER
' Zr-.- Date Signature of Contlbct ///
U ° / OWNER-BUILDER DECLARATION SANTA ROSA PLAZA,LLC(DAN BROWN) OWNER -BUILDER
LU LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's P.O, BON I SO;f
~ 0) License Law for the following reason: LA QUANTA CA 122`3
Z ( ) I, as owner of the property, or my employees with wages as their sole ( ) • c_rBLII
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 KI IBC"ITtIC?1.
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
c () I am exempt under Section , B&P.C.for this reason ADDITIONAL P1 FL''t7dIC.AL METERN
O N Date Signature of Owner
rn
d Z WORKER'S COMPENSATION DECLARATION
o . CCI hereby affirm under penalty of perjury one of the following declarations:
r I— O ( ) 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
Om - Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers'compensation insurance,as required by
m 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
0: rn I- permit is issued. My workers' compensation insurance carrier & policy no. are:
c
v — Polic
y No. WC9492873 ESTIMATED COST OF CONSTRUCTION 0.00
r- a PERMITS'. ESUMMARY
5 (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEE 101.000-420.000 133,50
( ) 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 f S_ection.'3700 of the Labor
Code, I_s�ball fy�14hwith comply with those provis` ns, ;
Date: 1/ /1 j.- AppliEant-,L -(1 -F A -a-a-4--
w Warn ng: 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
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
lirapplication.
1.Each person upon whose behalf this application is made&each person at tIII-TOTAL I"O)42TIcU&`IIUN AND PLAN CHECK $33 50
whose request and for whose benefit work is performed under or pursuant to n
any permit issued as a result of this applicaton agrees to,&shall,Indemnify D U LESS PRE-PAID FEES $O,OU
& 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 J PERMIT PIKES DUE NOW ',MN)
work is not commenced within 180 days from date of Issuance of such MAR 1 7 2004 =J
permit, or cessation of work for 180 days will subject permit to cancellation.
, tr.
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 representatives of this City to enter upon
the above-mentioned property for inspectio purposes:
/ j _.�� / /diECEIPT DATE BY DATE FINgLEED_ z INSP Tag,..i
Signature (Owner/Agent r :'�'. Date-y/ ,119`." 6 Y T ` L
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR 1
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Fors 8 Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
O.K to Wrap FA.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 Tcp 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)