0203-015 (ELEC) UCENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
CO 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 TRACT
c"a CO Professionals Code,and my License is in full force and effect. 0203 0th
p P el License it ,/Lic.Class Exp.Date JOB SITE .i� 11.: `AXLk Pi MN
1 lu. " ADDRESS
1-- :44:71 trt OJIIC 4/30/02 OWNER !'l 5., ri 1if S'If,1.1'at,x? F.t LW: f rlRI CONTRACTORI DESIGNER/ENGINEER -
Z r� Date Signature of Contractor
8Or
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OWNER-BUILDER DECLARATION
H a I hereby affirm under penalty of perjury that I am exempt from the Contractor's Ntd-C1,1A/1 HECJCII?.ELECtIRLCAL r'r)NTRALI OR3INC
co License Law for the following reason: 81.IOU AVM LIE 53 18.105 CAU4 I.31A.DO,3131T E Is
Z ( ) I, as owner of the property, or my employees with wages as their sole IA Qi.IASTA LA QJTNTA CA 9225'?,
compensation,will do the work,and the structure is not intended or offered for (760)771-5553 CBI A 718
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 la ACM;C'A!,
Code).
o) () I am exempt under Section , B&P.C.for this reason 100 AMP l KOESTAI.'I'D fitt'.WED FOR(t LF CART CI
rn
N Date Signature of Owner
0 N ..
O)
Q WORKER'S COMPENSATION DECLARATION
o Q i I hereby affirm under penalty of perjury one of the following declarations:
in r F O O I have and will maintain a certificate of consent to self-insure for workers' 'VALUATION M'O('U L:,
X w LL compensation, as provided for by Section 3700 of the Labor Code, for the
m ---I 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 ceSection 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:
d Z Canter Policy No.
QS O STATE FUND 046 118Mt1' ESTIMATED COST OF CONSTRUCTION 500.00
Q (This section need not be completed if the permit valuation is for$100.00 or less). FERMI/Fb.'E S'IUMMARY
( ) I certify that in the performance of the work for which this permit is issued, L/.LBC"fIU)CAL FEE 101.000.420•000 SYS50
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 3702 of the Labor
Code, I shall forthwith comply with those provisions. ;
Date: Applicant de-F -• ,�' '::�4;
Warning: Failure to secure Workers'Compensation coverage is unlawful and
shall subject an employei to criminal penalties and civil fines up to$100,000„p, .
addition to the cost of compensation,damages as provided for in Section 3706 .
csr
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.. N
application. f
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 >T AL,CONIMUCFION AND PLAN C I-IE f..1C t3"5O
t any permit issued as a result of this applicaton agrees to, &shall, Indemnify 1.13w PRE-PAID Fur; $O.Of l
& hold harmless the City of La Quinta, its officers, agents and employees. -a,0
2.Any permit issued as a result of this application becomes null and void if p �;- I'ata.i'ERNLI T A'I`:'ES MIT NOW 4$0.0 i
work Is not commenced within 180 days from date of issuance of such 2rT '�`
permit, or cessation of work for 180 days will subject permit to cancellation. ,D o
I certify that I have read this application and state that the above information is �0tv1�� 0)
' correct. I agree to comply with all City, and State laws relating to the building t3 C
construction, and hereby authorize representatives of this City to enter upon : ~>I rw s �� _ �r
the above mentioned property for inspection pufposes. ?C j�iK�� / ,��
- RECE PT L LATE BY DAtE.FINALED INSPECTOR
Signature (Owner/Agent) - Date
9 ( 9 ) j
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms&Footings Ducts
Stab 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 Neater Final —
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure r
Shower Pars O.K.for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection Encapsulation
Gas Piping — — — — —Gas Test
Appliances _
Final
- COMMENTS:
--
Final __—
Utility Notice(Gas) 1
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
SC)Panels
Z terior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)