0202-202 (ELEC) LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
I- Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT I:!.02, 3:::0 TRACT
CV W Professionals Code,and my License is in full force and effect. MOM)
D co License# Lic.Class Exp.Date p -
JOB SITE APN
h �, ti 748171 CIOI3TC t14130,2( ADDRESS 52-98,`51/ w1 �1'r.AOE CLUB U� - -
O Zr-.. , Date :'-Z G ---,Signature of Contractor / OWNER CONTRACTOR(DESIGNER/ENC,INEER
o OWNER-BUILDER DECLARATION NW-CI,LLC UEOCilr'ELftC`'T t1CAL COI1' ROPTORS WC
W IA - I hereby affirm under penalty of perjury that I am exempt from the Contractor's 81'1 D4 AV MS 53. '/8-10 F CALLE PDO AT B
U) License Law for the following reason: LA QIngrA LAQUINI'A CA .92233
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)771-5 53 MIA218
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 Fi.,ECTR1CAL
Code).
() I am exempt under Section , B&P.C.for this reason_ PKI"Ji STr1.L.S FOR 1.A.KEES AND BU UXI-KM
tn
N Date Signature of Owner _
ON
ZWORKER'S COMPENSATION DECLARATION
o IY 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 300,00 IA
X W LI- compensation, as provided for by Section 3700 of the Labor Code, for the
m -1 - 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: 2 1— permit is issued. My workers' compensation insurance carrier & policy no. are:
cb D Lamer a ATj Filil Policy No. 046 t ty3►t' ESTIMATED COST OF COl'l12UC IO1I :500+.d�E?
r` a PERMIT FIEF SUMMARYp
5 (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEE 101-001-420-000 $33 51
( ) 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
Code,I shall forthwith comply with those provisions.
Date: Applicant
,e.,-'
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
of the Labor Code,interest and attorney'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
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 81.1E- O AL CON RUCTION AHD PLAINT CHECK $.1 3 it)
any permit issued as a result of this applicaton agrees to, &shall, indemnif •y'.' PRE'PAID FEi' SUCK)
& 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 I l,� t T .P PAW, a:53n
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. r,?_ �'
I certify that I have read this application and state that the above information is c1 4t - (- '-�' ;
t correct. I agree to comply with all City, and State laws relating to the building \-.k.)
construction, and hereby authorize representatives of this City to enter upon .� �TFz ': l
the above-mentioned property for inspection purposes. ' '` `/%�'f�CJ _
RECEIPT DATE . -- " BY ATE FINALED fSPEC OR
Signature (Owner/Agent) Date !
•
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 Heater Final
Water Piping Plumbing Final
Plumbing Top Out Equipment Enclosure
Shower Pans _ O.K.for Finish Plaster
Sewer Lateral _ _ Fool Cover
Sewer Connection Encapsu lation
Gas Piping — — — — —
Gas Test — — — • - __
Appliances
Final
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
_Temp.Power Pole 1 J
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service -
E ub Panels—— — -- --
Exterior Receptacles
G.F.I.
Smoke Deter tors -- --
Temp.Use of Power
Notice(.Perm;