0202-201 (ELEC) LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
II-- Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE VALUATION LOT �r,F'. ` '`�ti TRACT
CV W Professionals Code,and my License is in full force and effect. • - $5+(rp1/1f3(J
License# Lic.Class Exp.Date
JOB SITE APN
o w t ;/2,t1;i; {�i(1FliC ,!r t.,�i;� ADDRESS 52-•941 IaJEFFERSONYITI T -
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oZ N. Date.,,- ,'-% cSignature of Contractor . _ OWNER CONTRACTOR/DESIGNER/ENGINEER
Or`
Ni U o OWNER-BUILDER DECLARATION 41J-CI,LLC. 1•31sa(l:E ELECTRICAL CONTRA{TORSiNC
W W ~ I hereby affirm under penalty of perjury that I am exempt from the Contractor's 6)A 00 AVI?Tt1E 5:4 7(3•]05 CA'YLLE ELME)O1 Stull Et
~ u) License Law for the following reason: LAQUINto LA QtJitTrA CA 9225?
Z ( ) I, as owner of the property, or my employees with wages as their sole (760)771.553 C'BJ..ii 218
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 ELEC1T ICAL
Code).
cn KIIE
() I am exempt under Section , B&P.C.for this reason PSTAL.;PUk LA< AND t3UILDINQS.
N Date Signature of Owner
O �
a Q WORKER'S COMPENSATION DECLARATION
o Q I hereby affirm under penalty of perjury one of the following declarations:
r H O ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION 500,00 1.0
X W Li- 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 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
0: rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
ao Z Cartier 'a!.t:' ±.FUND D Policy No. Cp!ti IKON ESTIMATED COST OF CONSTRUCTION '300 bo
N. O PERMIT'FEE g{MMARY
(This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL tin 101-000-421)-000 >•{.t,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
lasubject to the workers'compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. ;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
addition to the cost of compensation,damages as provided for in Section 3706
Qr.
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
ir
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 SUB-TOTAL CO}[ST uctiOT•T AALD PLAN('} CK $33.50
any permit issued as a result of this applicaton agrees to, &shall, indemnify /, i t ; • l�+ S .['F.1 �PATI5IT:� '�O.UV
& hold harmless the City of La Quints, its officers, agents and employees. • -�f �a -•- ;
2.Any permit Issued as a result of this application becomes null and void If '!: TAI. ,
work Is not commenced within 180 days from date of issuance of such `-r' n c� �111] 1-. • p` 1r]U L)IJ. : NOW
permit,or cessation of work for 180 days will subject permit to cancellation. F r�7 F. �• �vUL
I
I certify that I have read this application and state that the above information is
----
ct correct. I agree to comply with all City, and State laws relating to the building t`t�6YO��-r� llb?�'P1
tits�Y'•.a 1
construction, and hereby authorize representatives of this City to enter upon �" fj —
the above-mentioned property for inspection purposes. • ?' �<X T 'e--i'r-
RECEIPT DATE BY ATE FMALED INSPECTOR
Signature (Owner/Agent) Date ` i/
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms 8 Footings Ducts
Slab Grade Return Air
Sty 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
Party Wall Insulation Condensate Unes
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 Unes 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
- — 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 Detectcrs
Temp.Use of Power
Final
Utility Notice(Perm)
11