0202-204 (ELEC) LICENSEDCONTRACTOR DECLARATION
V) I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT PERMITW
ri)E" Chapter 9 (commencing with Section 7000) of Division 3 of the Business and ,
Csi DATE VALUATION LOT ;, S `C.1-1
LV Professionals Code,and my License is in full force and effect. TRACT
E. ,
= 0, License# Lic.Class Exp.Date
500.00
▪ Lkj ADDRESS APN
Tr . 7`i i I i'1Lr fTfl', 0t/3 �2f JOB SITE 6! -.°4+1.�1�VILLAGE MUD . .
• 0 h Date !Signature of Contractor -� • OWNER CONTRACTOR/DESIGNER/ENGINEER
w OWNER-BUILDER DECLARATION ]k-C1,LLC
ffit::Ciuli Ia..ECTRICAL.CONTkA�'�C RS ltvC'.
W a I hereby affirm under penalty of perjury that I am exempt from the Contractor's 81-100 AVENUE 53. 78.1 QZ CALLE&`3PAD°,SUITES D
Cn License Law for the following reason: LA QUINTA LA.QUfl TA LA 92253
Z ( ) I, as owner of the property, or my employees with wages as their sole (')6r�}]7]-55,53 CB1 it 218
compensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044, Business&Professionals Code). -USE OFPERMIT
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044. Business & Professionals $LEC.R1CAL
Code). -
LO
co () l am exempt under Section , B&P.C. for this reason t'2:17F i'TAI.S FOR LAKES AND BUILD1t4US.
O N Date Signature of Owner
a)a Q WORKER'S COMPENSATION DECLARATION -
to
mt
o Q Q I hereby affirm under penalty of perjury one of the following declarations:
r p- O ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION 500.00 LE:
X iii a compensation, as provided for by Section 3700 of the Labor Code, for the
m Q performance of the work for which this permit is issued.
Q (.,) ( ) I have and will maintain workers'compensation insurance,as required by
O 0 Section 3700 of the Labor Code, for the performance of the work for which this
d a) Z permit is issued. My workers' compensation insurance carrier & policy no. are:
con Carrier :�;TA 1'S l,Jt Policy No. 046 118302 �TIM COST OF CONSTRUCTION IO -500.00
QJ (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEE ]01-L100-�j.'0 QDO $33.30
( ) 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
subject to the workers'compensation provisions of Section 3700 of the Labor
4 Code,I shall forthwith comply with those provisions.
Date: ' Applicant • -`• ' ._ .
r W
- Warning: Failure to secure Worker& Cortlpensation 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 attorney'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
4
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
S�1 r. I;OTAL CaISTt UCT7ON AND PLAN CHECK '$3:1.50
*II* any permit Issued as a result of this applicaton agrees to, &shall, indemnify -g r—_� � �_-- ;r LASS PR -PA$]FEESO.OU
& hold harmless the City of La Quinta, its officers, agents and employees. ,f
2.Any permit issued as a result of this application becomes null and void if IW 2111.) 3 T�L.PERMIT It S DUE1NOW3.15Q
work is not commenced within 180 days from date of issuance of such I.Li r r 2 c l
permit, or cessation of work for 180 days will subject permit to cancellation. li ----- -.ter
I certify that I have read this application and state that the above information is �1d � "_"' dEbal�
th
correct. I agree to comply with all City, and State laws relating to the building �__-__�r-_._� �.i.. �
construction, and hereby authorize representatives of this City to enter upon / '�;the above-mentioned property for inspection purposes. RECEIPT DATE . BYfx/c),,, ..ft
E FINALED INSPECTOR
Signature (Owner/Agent) Date '�'/
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE 1 INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Sat Backs I 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
Electric Final
Waste Lines Heater Final
Water Piping - - Plumbing Final
Plumbing Top Out — - Equipment Enclosure
Shower Pans _ O.K for Finish Plaster
Sewer Lateral _f Pool Cover
Sewer Connection Encapsulation
Gas Piping --— - - -- -
Gas Test -- — _—
APPliances
I 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. _ I
Smoke Detectors
Temp.Use of Power
F'�at _ _
Ut.. y Notice(Perm)