0403-436 (ELEC) I
LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
En I hereby affirm under penalty of perjury that I am licensed under provisions of idQ3 33+�
I-- Chapter 9 (commencing with Section 7000) of Division 3 of the BGsiness and
DATE VALUATION LOT TRACT
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uj Professionals Code, and my License is in full force and effect. .r,I{i,tl:! - nt961
M cq License# Lic.Class Exp.Date
r� LQLI R i;*f, M..k i :10 e i 1,,, ; '.; ADDRESS s .t5fi 116 niu,Ti15RUi. . . APN
/1:L N Z ti Oats ' ' Signature of Contractor ' ' OWNER • CONTRACTOR/DESIGNER/ENGINEER
U cOD r OWNER-BUILDER DECLARATION INNOVATIVE RESORT CONIMC1Ni'.1`13S,INC S.R. ItR_PLii' CORP,:it+u POWEF?PI
W LV I hereby affirm under penalty of perjury that I am exempt from the Contractor's 2001 E. WAJ}T11�1CiTON AVE, #]OD 681 S. }'AliK1'R�7 5IF iU0
~ u) License Law for the following reason: }SCONDIDO CA )2025 ORANGE CA 92868
Z ( ) I, as owner of the property, or my employees with wages as their sole (714)764-002o C13I.4 1881
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 FL;CTRI ,y1
contractors to construct the project (Sec. 7044, Business & Professionals .
Code). 1 100 AMP TEMP POWER POi.E.2001 Cflr.
co () I am exempt under Section_ , B&P.C.for this reason
in
N Date _Signature of Owner
o �
WORKER'S COMPENSATION DECLARATION - -
p a- I hereby affirm under penalty of perjury one of the following declarations:
- H p O I have and will maintain a certificate of consent to self-insure for workers' VALUATION UD,PO ! '
X W II- compensation, as provided for by Section 3700 of the Labor Code, for the
0 Q performance of the work for which this permit is issued.
CCiQ U ( ) I have and will maintain workers'compensation insurance, as required by
O U Section 3700 of the Labor Code, for the performance of the work for which this
0: I- permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier ;\-!'H' i'Uivl; Policy No. i 'yy))‘:-,i!o ESTIMATED COST OF COI'J ERt1 UOP1 500.00
N- a PERWF 1<' 'L&`4MMARY
(This section need not be completed if the permit valuation is for$100.00 or I s). FIECTR1CA1.FEE 101.000-420=000 Jfl.00
( ) I certify that in the performance of the work for which this permit ised,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of Califomia,,and agree that if I should become
subject to a wo kers' compensation provisions of Section 3700.of the Labor
,,
Code, Ish JI 7 v comply with those provisjons.
ta
Date: t ( Applicant i 1 1 [� d r '
Sib
Warning: Failure to secure Workers' Compensation coverage is unlawful and U II i
shall subject an employer to criminal penalties and civil fines up to$100,000,in e np I
addition to the cost of compensation,damages as provided for in Section 3706 MAR 3 0 ZQD ,J
cisp,
of the Labor Code, interest and attomey's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety CITY Cr LA C,U! I;',
irfor a permit subject to the conditions and restrictions set forth on his Ff-'PAf CEI?`1'T
application.
1.Each person upon whose behalf this application is made&each person at SU,..T 'MT,CONSTRUCTION AND PLAN CHECK $_�O.GO
whose request and for whose benefit work is performed under or pursuant to
."/:21h any permit issued as a result of this applicaton agrees to,&shall,indemnify 1` S PRE-PAU3.F'e. ,t 0 00
& 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 TOTAL PERMIT FEES iUF Now S.1.41.0(1
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.
I 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 authorize.representatives of this City to enter upon.
the above-mentioned property for inspection purposes. /
T. r RECEIPT DATE / BY DATE FINALED INSPECTOR
Signature (Owner/Agent) '/ Date '
INSPECTION RECORD
OPERATION i DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs le/°6( 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 UnesHeater Final
Water �7 /V Plumbing
Final
Plumbing Top Out Equipment Enclosure
Shower Pans _ O.K for Finish Plaster
Sewer Lateral Pool Cover
Sewer Connection jJ Encapsulation
Gas Piping _R
Gas Test _
Appliances
Final
COMMENTS:
Final
Utility Na ce(Gas)
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 /_O Cr/ Q 6d L
Final
Utility Notice(Perm)
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