0202-198 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
(n 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 6'2OJ2"i rJ TRACT
N W Professionals Code,and my License is in full force and effect. 1
al ch License# Lic.Class Exp.Date
t' Q Ilj JOB SITE APN
r` re ti 7�tg173 f:''i C� CY :� ()WW2( ADDRESS 52-991 l.,VILLAGE CLUB 1bR1V - _
0 Z Date,—`'? c, nature of Contractor ' OWNER CONTRACTOR/DESIGNER/ENGINEER
COO I � .�-'
t` F-
-IP2 1 OWNER-BUILDER DECLARATION j(U- j j c HECkili 1:1.kt'11t1CAL CONT ACTUla2 MCC
I-- W n I hereby affirm under penalty of perjury that I am exempt from the Contractor's 81.100 AVENUE 53. 78-167 CAILE ES ADO,SUS 1
License Law for the following reason: .1,A QuarrA LAQU;J l TA CA 172 5a
Z_ ( ) I, as owner of the property, or my employees with wages as their sole r<76D3771-5iS3 �`lsl.►1 Zl8
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 Pi:i✓C T UCAL
Code).
co () I am exempt under Section , B&P.C.for this reason PEDESTALS FOR LAKES AND BUILDINGS AND 320 HY PUMPS
to
O N Date _ Signature of Owner
rn
a Q WORKER'S COMPENSATION DECLARATION -
p cc I hereby affirm under penalty of perjury one of the following declarations:
r H 0 ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION 500.00 LS
X W I- compensation, as provided for by Section 3700 of the Labor Code, for the
O J - performance of the work for which this permit is issued.
CCI Q IJ ( ) I have and will maintain workers'compensation insurance, as required by
O Ca Q Section 3700 of the Labor Code, for the performance of the work for which this
Ci
rn I— permit is issued. My workers' compensation insurance carrier & policy no. are:
co D Carrier
:31'13.TF.FUND Policy No. itf6 I113382 ESTIMATED COST OF CONS'!' ti1CT`[QN 501100
ti 0 Fkl ilIT/ME SUMMARY
5 (This section need not be completed if the permit valuation is for$100.00 or less). ;LECTRICAL ITE I01.000 420.000 S60,50
( ) 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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
1 Code, I shall forthwith comply with those provisions.
I 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
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 °:
airapplication.
•
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 toUE3-TCYI'dG C'ONIt[T4"1'tOpI AND PLAN C'.11Er,ll`0
"12*26 any permit issued as a result of this applicaton agrees to, &shall, indemnify • LESS PRE"P•�FEES C''00
& hold harmless the City of La Quinta, its officers, agents and employees. bf•I t _ L I '.
2.Any permit Issued as a result of this application becomes null and void if ! ,11? [y��'O'jt�DUE NOW
work Is not commenced within 180 days from date of issuance of such 2 2 ���� t�
permit, or cessation of work for 180 days will subject permit to cancellation. FEB
I certify that I have read this application and state that the above Information is -I r
• correct. I agree to comply with all City, and State laws relating to the building ary 0� 4��� A
construction, and hereby authorize representatives of this City to enter upon r:pme '•c7in � �� , •/fJfj�
the above-mentioned property for inspection purposes. RECEIPT DATE y &Y ATFINALED INSPECTOR
Signature (Owner/Agent) Date - ,; ' ._' .-' .
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts
Forms 8 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 I O.K.for Finish Plaster
i Sewer Lateral _ _ _ Pool Cover
r Sewer Connection I Encapsulation
Gas Piping
Gas Test
Appliances
.— __ _--- - -- ------— Final .—.
• — ---- -- - COMMENTS:
Final
Utility Notice(Gas) -- T
ELECTRICAL APPROVALS
Temp. Power Pole _
Underground Conduit _Rough Wiring
Low Voltage Wiring
Fixtures —Main Service
Sub Panels
Exterior Receptacles
G,F.I.
Smoke Detectors
Temp.Use of Power -- - --
Final
Utility Notice(Perm) — s