0211-077 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMITS
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 �11 OTT TRACT
CNI W Professionals Code,and my License is in full force and effect. 1]/UB/20G $2,000di[) 2989-1
p D co 1 License it Lic.Class Exp.Date
r` JJ 'IC 0748171 C10 HIC 04/30/2( ADDRESS 52-552 1/2 VILLAGE CLUB DRIVE APN -
NrZ ^ Date f//— Signature of Contractor C.> l✓ ids OWNER CONTRACTOR/DESIGNER/ENGINEER
O O ,
r� V o OWNER-BUILDER DECLARATION -LQF'LLC 1 CICIE Fl.FCIRICAL CONT P AC'IDRS INC
J
W Wct, ^ I hereby affirm under penalty of perjury that I am exempt from the Contractor's 81-I00 AVENUE 53 7R 105 CA[d E P.eiTADCD,SUITE P.
CO License Law for the following reason: I A(�UINTA L ti. ff225? LAl UINTA CA 922S
Z ( ) I, as owner of the property, or my employees with wages as their sole (760)771-5553 CUR 718
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). 200 AMP Pi. '.CTRICA1.PEDASPAL(0 CART BARN
CO
CO () I am exempt under Section , B&P.C.for this reason
N Date Signature of Owner
OCM
d Q WORKER'S COMPENSATION DECLARATION
o ix I hereby affirm under penalty of perjury one of the following declarations:
La H O ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION 2,000.00 III
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
Om -I Q performance of the work for which this permit is issued.
Q O (,a I have and will maintain workers'compensation insurance,as required by
O O Q ecb gon 3700 of the Labor Code, for the performance of the work for which this
d rn F— permit is issued. My workers' compensation insurance carrier & policy no. are:
1. Z Cartier STATE FUND Policy No.
5046 118302 ESTIMATED CM OF CObISTRUC non 2,0410.00
I O PERMIT FEE SUMMARY
(This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL•PFDItSTA-1.. 101-000-420.000 S33,50
O 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
Code,I shall forthwith comply with those,provisions.
/Date: ,,/C//r. Applicant /
Warning: Failure to secure Workers' Compensation coverage is unlawful and
Ili a� IJ
shall subject an employer to criminal penalties and civil fines up to$100,000,in
1 addition to the cost of compensation,damages as provided for in Section 3706
of the Labor Code,interest and attomey's fees. 1 9 /I Itl�
il
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 CITY OFFLAQUINTA
airapplication. FINANCE DEBT. :A'
1.Each person upon whose behalf this application is made&each person at 1
whose request and for whose benefit work is performed under or pursuant to BUR- OVA.1..CO T' RUT ION/LAND Z}LAN CHECK $:33.S0
any permit issued as a result of this applicaton agrees to, &shall, indemnity LR3: PRE-PAID FEE2I SQ.00
$
& hold harmless the City of La Quints, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void If Tt70'lAL PL'RMJT MEE.DUE NOW 3.50
work is not commenced within 180 days from date of issuance of such
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
' correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon _ ppp�y
the above-mentioned property for inspection purposes. • e /1 RECEIPT = DA ALEX 9�/l D JD Jl�
DATE 9Y �_-__ INS�ECTOR
Signature (Owner/Agent) Date '/// I, —Y
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&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 l 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 i
�- -- - COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
_Rough Wiring
; Low Voltage Wiring
Fixtures
Main Service A
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)