0401-276 (ELEC) LICENSED CONTRACTOR DECLARATION PERMITS
CO I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT 0401 2/c.F- Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE ,�,/4,i14 VALUATION &KI r<�,i;ll LOT
re W Professionals Code,and my License is in full force and effect. TRACT
C m (0 License a Lk.CI Exp.Date __
r 14.1 0 r 6871kr,0 D37/l:/�J�C133 4/3r JADDRESS 53-9431/2MADISONSTREET APN - -
O' Zr- Date 2/0/Signature of ContraetOr /�/ �/ `!w �� OWNER CONTRACTOR/DESIGNER/ENGINEER
V m OWNER-BUILDER DECLARATION N.D.LAQUINIAPARTNERS,LLC NATIONAL CONST UC7IONRENT"
I—til d I hereby affirm under penalty of perjury that I am exempt from the Contractor's t31••140 AVENUE 53 p,0,BOX 4503
co License Law for the following reason: 1�Q1 rA CA 92253 PACOIMA CA
Z ( ) I, as owner of the property, or my employees with wages as their sole (600)952-5675 CELL!
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 E',EI.FRJCAL
contractors to construct the project (Sec. 7044, Business & Professionals
Code). 208 AMP UM, PGWEK FDLt rx. 13Uo TOLE
t'') () I am exempt under Section , B&P.C.for this reason to
O N Date Signature of Owner
U a
11 C WORKER'S COMPENSATION DECLARATION
0 Q Q I hereby affirm under penalty of perjury one of the following declarations: VALUATION 600.00 LS
I— O ( ) I have and will maintain a certificate of consent to self-insure for workers'
x W LL compensation, as provided for by Section 3700 of the Labor Code, for the
m -1Q 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 < Section 3700 of the Labor Code, for the performance of the work for which this
d rn I- permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Cartier i?/;Vli ..t.,:c.' Policy No. T'i1JWi419JdD1-7.03 ESTIMATEDCOSTOFCONSIRUCIION t'a'
oob O PERMS1 FEE SUMMARY
n (This section need not be completed if the permit valuation is for$100.00 or less). •
ELECTRICAL PEE 101.O00.420 000 5:77.5O
( ) 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-_
a subject to the workers'compensation provisions of Section 3700 f theeLaabdi I
Code,I alli�orthwith comply with those provisi s. �j/� r—\ I`
�.Dale: - . �y Applicant , i i' ` `�� EEB
- II
Warning: Failure to secure Workers'Compensation coverage is unlawful and I r� 5LJU1, `II,Jshall subject an employer to criminal penalties and civil fines up to$100,000,inIJ Q n 1
addition to the cost of compensation,damages as provided for in Section 3706 — - -of the Labor Code,interest and attorney's fees. ;,ti
iS
IMPORTANT Application is hereby made to the Director of Building and Safety �! _. - -
for a permit subject to the conditions and restrictions set forth on his y
airapplication.
1.Each person upon whose behalf this application is made&each person at SUB-TOTAL CONRTRUCTION AND PLAN CHECK .t_) :i
whose request and for whose benefit work is performed under or pursuant to LESS PRE-PAID PIT Sr,
tany permit issued as a result of this applicaton agrees to,&shall, indemnify& hold harmless the City of La Ouinta, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void if TOTAL P$RA41T FEES DUE NOW $:i 1..:a
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.
certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorizer resentativ s of thi Rity to enter upon
the above-mentioned propertylor in7spection oses.'.
i• RECEIPT DATE I BY DATE FINALED INSPECTOR
Signature (Owner/Agentj_ /-+>�'��'� Dat tom` r
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 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 I 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 Pool Cover
Sewer Connection Encapsulation
Gas Piping --- - -Gas Test
A,pl"races _
Find
COMMENTS:
Final
Utility Notice(Gas) _
ELECTRICAL APPROVALS
Temp Power Pole
Underground Conduit
Rough Winng
Low Voltage Winng
FMAures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)