0202-199 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMITN
to I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT C&2Ll . 199 TRACT
coCNI Professionals Code,and my License is in full force and effect. $500,Iyl1
p = el License N Lic.Class Exp.Date JOB SITE
APN
ADDRESS
i C 10 tit:: t`wj,'a(;1;t 52.305.i1 VLI1.A.13 ..CLUB DRIVE, .. -
�' Z N. Date Signature of Contractor - .J ' , OWNER CONTRACTOR/DESIGNER/ENGINEER
co O ri '
U OWNER-BUILDER DECLARATION NAI-C1,T.Lt-" REUCif�ELF.C'r 1c. L c'ONTRACrcl c
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 81.100.AVENLIF 5'f '78,1 05 C~ ,I,T?,"FAD';),�;Lli'1 'B
Z
License Law for the following reason: LA QtUNTA LA,QUQ _�rl'A /.'A 922`.-
( ) I, as owner of the property, or my employees with wages as their sole (760)171^•5553 C.'E l.4ii 2.18
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
contractors to construct the project (Sec. 7044, Business & Professionals .ELL IRICAL
-
Code).
co () I am exempt under Section , B&P.C.for this reason PIIDLr.STA,1.3 FOff L.AKP_'S AND BUILLANCIS AND 3, II fW PUMPS
in
Date Signature of Owner
ON
CI)
WORKER'S COMPENSATION DECLARATION
io Q Q I 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' VALUATION 9113.0 L S'
X W Y compensation, as provided for by Section 3700 of the Labor Code, for the
mJ Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers'compensation insurance,as required by
O 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
d la I— permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z_
00 5 Canes 3"I'ATE FUND Policy No. r (3i'4.3t? ESTINIAIT.D COST OF C:ONu PdmC"# ON (11?.!k}
QJ (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEE l 01-000.420 'a; ,SO
( ) 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 workers'compensation provisions of Section 3700 of the Labor
j Code,I shall forthwith comply with those provisions. . '
f '
i Date: Applicant ,
Warning: Failure to secure Workers'Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to$100,000,in
1
1addition
to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attorneys 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-
whose request and for whose benefit work is performed under or pursuant to BIM-TOTAL CONSMICTIM AND Pt.A) (ISM s.m'. CI
":* any permit issued as a result of this applicaton agrees to, &shall, indemnify t I .`3 PP-II-PAID T�F1�.,`' ;¢t�,Lip
& 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 ' •'
work is not commenced within 180 days from date of issuance of such } � 'l'FItMs] IrP.S I)Zl:� itW7f ,;yf}
permit, or cessation of work for 180 days will subject permit to cancellation. _1 ,' ,.'` /'Ijt-1
:]
I certify that I have read this application and state that the above information is
t correct. I agree to comply with all City, and State laws relating to the building 'e_.=..0:J,1T.1,
construction, and hereby authorize representatives of this City to enter upon -.. �__,,_1
the above-mentioned property for inspection purposes. ,
RECEIPT DATE liiY DAV FINALED INSPECT
•
Signature (Owner/Agent) Date i ''- r `/ I
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
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 - T
Party Wall Insulation Condensate Lines
Party Wall Firewall •
Exterior Lath
Drywall-Int.Lath .
Final _
Final- POOLS - SPAS
I
BLOCKWALL APPROVALS Steel--
—
Set Backs - TElectric Bond
Footings Main Drain
Bond Beam `Approval to Cover
__Equipment Location
Underground Electric
_ Underground Plbg.Test
Final _Gas Piping
PLUMBING APPROVALS h_GasTest
_ l Electric Final
Waste Lines Heater Final --
Water Piping Plumbrig Final i
Plumbing Top Out --I-Equipment Enclosure _
rh0werPans O K for Finish Plaster 1
ewer Lateral -� F}oi Co::r
Sewer Coinection EncapsLIa on -
rGas Piping I -----+
Gas Test -- - ---- �- - I --
Appliances
i — - - Final
COMMENTS:
i
Final
Utility Notice(Gas) i--
ELECTRICAL APPROVALS
Temp Power Pole i ! 7) - I
Underground Conduit 1-
Rough Yri ir, --
Low Voltage VVinng 1
Fixt rr -
r
Main Seiv ce - - - 7 Sub Panels —
Extelior Receptacles - -- - \ / ,
\,
_Smoke_Detectors -_
\ /
1 emp.Use of Power - --___
/
Finat '-'-"- , •
Utility Notice(Perm) _- � - jc Pr