0202-200 (ELEC) LICENSED CONTRACTOR DECLARATION PERMIT!
N 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 0202 200 TRACT
CM W Professionals Code,and my License is in full force and effect. Zt},f70
o = cr) License# Lic.Class Exp.Date
JOB SITE APN
r; w ti 748171 CI 0 JC 04)30l2( ADDRESS S .1.72 in J1+:F t ERSON STREET - -
N.
Z N. Date Signature of Contractor_ ---�'� OWNER CONTRACTOR/DESIGNERIENOINEER
N. U m "`-- OWNER-BUILDER DECLARATION NR1-C` ,1LC H1GG FL&Tii lC1�.CO'NTRACTORs INC
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L W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 01.1 0 AVKNIJI?53. 78-1 U3 C'ALI..E IL-x'AXX),5urrE L'
~ y License Law for the following reason: LA QU,[N9;A LA("XENIA CA 92253
Z ( ) I, as owner of the property, or my employees with wages as their sole r
f?6t3)771.3�i3 G'Ba.# 210
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 '' EC•1•1.41'-•
Code).
cr) () I am exempt under Section , B&P.C.for this reason PSOF•S'ALS VCR LAKES AND BUILDINGS AND a 15 HP PtJMP3
N
O N Date _Signature of Owner
0
a Q WORKERS COMPENSATION DECLARATION
o .e cc I hereby affirm under penalty of perjury one of the following declarations:
r FQ-- O ( ) I have and will maintain a certificate of consent to self-insure for workers' VAkUATXUN 500.0% ?'.'i
x W LL compensation, as provided for by Section 3700 of the Labor Code, for the
m -I 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
3: 69 Z permit is issued. My workers' compensation insurance carver & policy no. are:
co 5 Carrier 3't.sr �.ri.1L Policy No. I,y,: !:`::;n ESTIMATED COSI'OF CONSTRUCTION "430.00
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PTiCRML'f'v7Te SUMMARY
(This section need not be completed if the permit valuation is for$100.00 or less). MAC?MAL FEE 101-000-420F000 S76.30
( ) 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
i , I shall forthwith comply with those provisions.
Date: Applicant
is 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
cs,
of the Labor Code,interest and attomey'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 is made&each person at
whose request and for whose benefit work is performed under or pursuant to SUB-IaLAl.COp[S1C2U(~i'.C?ti AND PLAN CHECK1>3. 11
any permit issued as a result of this applicaton agrees to, &shall, indemnify LE PRE-PAIL F ri :LA OE1
& 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 f j r ''Aj,F� '�[PSUt NOW fh7f,1_ b
work is not commenced within 180 days from date of issuance of such `f , ti 1
permit,or cessation of work for 180 days will subject permit to cancellation. >
I certifythat I have read this application and state that the above information is2 c n t1.
$1.
correct. I agree to comply with all City, and State laws relating to the building , ���`,� r1
construction, and hereby authorize representatives of this City to enter upon S.,T I •
# 1 ��, � r '/�
the above-mentioned property for inspection purposes.
RECEIPT OAT BY DATE FINALED INSPECTOR
Signature (Owner/Agent) Date ' ' • i
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 _ T _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
Ir
Main Service
1 Sub Panels Exturior Receptacles
G.F.I, •
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm) -