0403-183 (ELEC) LICENSED CONTRACTOR DECLARATION PERMrr#
co I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
I— Chapter 9(commencingwith Section 7000) of Division 3 of the Business and fLlO t£KS
p DATE VALUATION LOT TRACT
04 W Professionals Code,and my License is in full force and effect. 0311(tf2(1( $1,200.110 Z4i1i,;8-A
p D License# Lic.Class Exp.Date
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r& n 7i7699 B 04/30/2( ADDRESS 56.191a MOUNTAIN VIEW 7t2 •120 022
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I ^ OWNER CONTRACTOR/DESIGNER/ENGINEER
, 2 N- Date ' -I N _ Signature of Contractor '`�'
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o OWNER-BUILDER DECLARATION 'PC1LL BROTHERS INC 'DILL BROTHERS INC
I j W -I3•12.) FRED WARING 01Ofi 73-1'2) FRED WAR Ci 0100
I hereby affirm under penalty of perjury that I am exempt from the Contractor's y qq
I— License Law for the following reason: PALM DESERT CA 92260 PALM DESERT CA 92260
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (760)674.9699 CPU/ 3832
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 ELECTRICAL
contractors to construct the project (Sec. 7044, Business & Professionals
Code). !RP-ILLATION PEDESTAL. 1001 CBE'
C'') () I am exempt under Section , B&P.C.for this reason
in
CtI Date Signature of Owner
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--. Z WORKER'S COMPENSATION DECLARATION
o 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' VAl.t1A'[ION 1,204 00 LS
X w La compensation, as provided for by Section 3700 of the Labor Code, for the
m - Q performance of the work for which this permit is issued.
Q C) ( ) I have and will maintain workers'compensation insurance,as required by
Cp 0 Q Section 3700 of the Labor Code, for the performance of the work for which this
D_ v I— permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier LIBERTY MUTUAL F. Policy No. WA262+,: :•-%730I2TI ESTIMATED COST OF CONSTRUCTION 1,206.00
I QQ PERMIT FIT SUMMARY
(This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL-PEDESTAL 101.Of00-420.000 t33,50
( ) 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
1a subject to the workers' compensation provisions of Section 3700 of the Labor
Code,I shall forthwith comply with those ovlsio s. -1
....-Date-�-1r Applicant- _'� %� D
A 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 MAR 11 2004 .,
addition to the cost of compensation,damages as provided for in Section 3706
vsof the Labor Code,interest and attorneys fees. CITY OF LA gUINTA
IMPORTANT Application is hereby made to the Director of Building and Safety FINANCE DEPT.
for a permit subject to the conditions and restrictions set forth on his
virapplication.
1.Each person upon whose behalf this application is made&each person at SUB-TOTAL CON zi i FitJ').KM i ND PLAN CHECK $33 0
whose request and for whose benefit work is performed under or pursuant to
t any permit issued as a result of this applicaton agrees to, &shall, indemnify LESS PRE.-PAID gam; TO`}/'
& hold harmless the City of La Quints, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void if TOTAL PERMIT FEES DUE NOW +•3._`41
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.
t 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.
r� RECEIPT DATE_ �V DATE FINALED INSPECTOR
/ `\
Signature (Owner/Agent)---. Sr_....—---.__ Date'' I
INSPECTION RECORD
OPERATION DATE 1 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 i Heater Final
Water Piping 1 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) V I
ELECTRICAL APPROVALS
Temp.Power Pole —
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors I
Temp.Use of Power
Final
Utility Notice(Perm)