0306-089 (ELEC) LICENSED CONTRACTOR DECLARATION � ., PERMITS
rA I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT USDA-UV)
I- Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE VALUATION ,i5110.Of1 LOT TRACT
w CO Professionals Code,and my License is in full force and effect.
License# Lic.Class Exp.Date
o Q lr1?f')7^i .I.
.. _. i 6130 ff.'7 JAZZES 60-450 3.2 'Z D APN . _
N- m 1 i .
�' Z f- Date ) ' Signature of Contractor ' ` ~ �� ( OWNER CONTRACTOR/DESIGNER/ENGINEER
8 O n ' ` UUFA1:O L'M
91WA 1i0A7F11,1.1 G
U OWNER-BUILDER DECLARATION I El-260AWG7UE62 41'260 MET Ut'62
W W I hereby affirm under penalty of perjury that I am exempt from the Contradtor's '17-11C,'1t1aLAL, CA 9288:3 T1 5Tt1AAL CA 92t3143
rn License Law for the following reason: i
Z ( ) I, as owner of the property, or my employees with wages as their sole (`�(IS+)b33" 0/� G76
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 FLECITUCAL,
contractors to construct the project (Sec. 7044, Business & Professionals
Code). ;4Lk..iilt'MEN;;: ?C.L/L'rtL
01 h () I am exempt under Section B&P.C.for this reason
O N Date Signature of Owner
a)d Q WORKER'S COMPENSATION DECLARATION
ole Q Q
I hereby affirm under penalty of perjury one of the following declarations: VALUATION S' _4,/,$
r E- O ( ) I have and will maintain a certificate of consent to self-insure for workers'
OJ La,J 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 U I have and will maintain workers'compensation insurance,as required by
idU 'on 3700 of the Labor Code,for the performance of the work for which this
cc
d rn I- permit is issued. My workers' compensation insurance carrier 8policy no. are: t'
' Z Cornier NATIONAL UNltQ1 t Policy No. C33'19 ;I;u MVO T D COST OF et'Ns-nu :oh 500.00
0N.00 O 2'3 t1Pf FKE flU MA�'Y
< (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEE )')1'000-4204)1X: $$,, c:.
( ) 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 Califomia, and agree that if I should become
a subject to the workers'compensation provisions of Section 3700 of the Labor
Code,I shall forthwith comply wit t' se ovisions.
ll fi , �`
gate: I. >�- Applicant �_ D /,�
Warning: ai ure to secure Workers'Compensation coversge is unlawful and J ^ D
shall subject an employer to criminal penalties and civil fines,up to$100,000,in JUN 0
addition to the cost of compensation,damages as provided for In Section 3706 - 9 ZOOS
of the Labor Code,interest and attomey's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety CITY OF LA QUINTA
for a permit subject to the conditions and restrictions set forth on his FINANCE DEPT.
ir
SUB- CrtiV COM/TRUC
application.
1.Each person upon whose behalf this application is made&each person at TION ANL, •i .AN CHECK 7?3.50
whose request and for whose benefit work is performed under or pursuant to
las any permit issued as a result of this applicaton agrees to,&shall,indemnify
&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 TOT4.L.DF.RMff P'L' 1 1.1JE NOW $1:4.50 l
twork 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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
RECEIPT DATE BY DATE FINALED INSPECTOR
Signature (Owner/Agent) •� Date ' II `• I-
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 FA.U.
Framing Compressor
Insulation Vents
Fireplace P.L. Grills
Fireplace T.O. Fans 8 Controls
Party Wall Insulation Condensate Lines
Party Wall Firevrall
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 ElaectriccFFinal
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
Appliances
Final
•
COMMENTS:
Final _
Utility Notice(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
Final
Utility Notice(Perm)
AT LA QUINTAHOMES - TRILOGYSHEA
TRACT NO. 30023
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