0202-203 (ELEC) LICENSED 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
coCNI Professionals Code,and my License is in full force and effect. 4:.1)0.00
O D el License# Lic.Class Exp.Date
JOB SITE APN
ti 0-1/3 On( ADDRESS 52,-987 1f2 VIM AGE GE CUM DRIVE
0 Z N. )f Date,-' Signature of Contractor t •�'� OWNER CONTRACTOR/DESIGNER/ENGINEER
cp
J U OWNER-BUILDER DECLARATION -i 1,L L.0 HEDGE la.pia i'Rki. L COIM.A.f"TOI<2INC
LU LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's 5)•-)00AVENJ1 53 78-703 CALLE ADO,SUF.1E.f3
I— License Law for the following reason: LA QUINTA LA QUI14TA CA 92233
Z ( ) I, as owner of the property, or my employees with wages as their sole t 'S0771.55S3 CIII.J0 2143
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 :ELECTRICAL
Code).
CO PEDESTALS( ) I am exempt under Section , B&P.C.for this reason PEDESTALS FOR LAKE i AND BUILDINGS.
In
N Date Signature of Owner
ON
— Z WORKER'S COMPENSATION DECLARATION
o cc 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' V ALIJ.A'i 1,01•4 300.09 Lk'
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
mJ 11 Q performance of the work for which this permit is issued.
Q C> ( ) 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
rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Carrier PolicyNo.
co D -rA'p!:Ftik4f) : ;. ..,: ESTIMATED COST OF CONSTRUCTION 500,00
r` 0 ]E'hktilirET'ia'S'tilvtA ,Y
(This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL,ZICsAL FEE. 01-0O0.420-000 Z33.30
( ) 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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.4 /
Date: Applicant ' .•l .y`�'r.-
r
'--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
for a permit subject to the conditions and restrictions set forth on his
44
application.
1. Each person upon whose behalf this application
lication is made&each person at
whose request and for whose benefit work is performed under or pursuant to s "TorAL CON RfiI "1'T47N fillb PLAK CHEck ' 3' O
any permit issued as a result of this applicaton agrees to, &shall, indemnify • LESS PRE`PA)J)YEES 0.00
& hold harmless the City of La Ouinta, its officers, agents and employees. /" .e f;
2.Any permit Issued as a result of this application becomes null and void if <` ..m—=_= }* AI,PERMIT FEES DUE lypW `
work Is not commenced within 180 days from date of issuance of such ti'
permit, or cessation of work for 180 days will subject permit to cancellation. F�=R Ll��1 -
f e� .
I certify that I have read this application and state that the above information is
• 16
correct. I agree to comply with all City, and State laws relating to the building -��� ��g�' , n`
li
construction, and hereby authorize representatives of this City to enter upon -•_•sneatlrwttET W:fv �� /C���
the above mentioned property for inspection purposes. RECEIPT DATE BY DA FINALED INSPECTOR
Signature (Owner/Agent) __ Date �.�1
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 Electnc
Underground Plbg.Test
Final I Gas Piping
PLUMBING APPROVALS Gas Test
Electric Final
Waste Lines Heater Final
Water Piping Plumbing Final
1 Plumbing Top Out Equipment Enclosure --_
Shower Pans O.K.for Finish Plaster
Sewer Lateral Pool Cover
Se ;er Connection ! Encapsulation
Gas Piping -- -
Gas Test
Appliances
Final
-
-- COMMENTS:
1 Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground Conduit
Rough Wiring -
Low Vottage Wiring
Fixtures
Mam Service
I Sub Panels
j Exterior Receptacles
G.P.I.
Smoke Detectors
Temp.Use of Power
..,J
Final
`` Utility Notice(Perm)