0307-113 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMITS
to I hereby affirm under penalty of perjury that I am licensed under provisions of
I— Chapter 9(commencingwith Section 7000)of Division 3 of the Business and 030/-1 I3
hap DATE VALUATION LOT TRACT
NI Professionals Code,and my License is in full force and effect. 07/Q9/20C $2,300.00
p D co License# Uc.Class Exp.Date
JOB SITE
1 .. w 789089 C•1 HI(" 12531./2( ADDRESS 77-264 10 CALLF MAZATLAN APN - -
o Z � Date Signature of Contractor
OWNER • CONTRACTOR/DESIGNER/ENGINEER
3On /
--1
V m ' OWNER-BUILDER DECLARATION CARLMC'C'ULLOGH CERTIFIED ELECTRIC 7RIC INrORPOPJULI)
W w I hereby affirm under penalty of perjury that I am exempt from the Contractor's 49'991 Elm' (?WF;F )�i781 POMERADO RI)#10 i
I— rz_CO License Law for the following reason: LA QUINTCA CA 92253 PO WAY CA. 92064
Z ( ) I, as owner of the property, or my employees with wages as their sole (856)486-1295 CEIL$$ ;L'D
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).
co () I am exempt under Section ,B&P.C.for this reason ELECTRICAL P817ASTAL,
in
OaN Date Signature of Owner
W
CL 'C WORKER'S COMPENSATION DECLARATION
o Q cc I hereby affirm under penalty of perjury one of the following declarations:
r H O ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION [300,00 l 3
X w l- compensation, as provided for by Section 3700 of the Labor Code, for the
0O -' Q performance of the work for which this permit is issued.
Q U ( ) I have and will maintain workers'compensation insurance,as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
d rn H permit is issued. My workers' compensation insurance carrier 8 policy no. are:
✓ Z
Z Carver STATE FUND Policy No. 1602223 ESTIMATED COST OF CONSTRUCTION 2,300,00
• O PERMIT FEE SUMMARY
'C (This section need not be completed if the permit valuation is for$100.00 or less).
ELECTRICAL—PEDESTAL l 01-(1(10 420-000 1;13.30
( ) 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 __.___�-
subject to the workers'compensation provisions of Section 3700 of the Labor D
re,\
Code,I shall forthwith comply with those provisions.
/date: Applicant V
JULrr11
% Warning: Failure to secure Workers'Compensation coverage is unlawful and U 0 9 2OU3
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 CITY Or L UINTA
of the Labor Code,interest and attomey's fees. FINANCE DEPT.
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 1
airapplication.
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-T�'�' UCZION AND PLAN CHFC'IC S33.50
wcz*. any permit issued as a result of this applicaton agrees to,8 shall, indemnify LF95 PREPAID FEE. $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 F'FXS DUE NOW work is not commenced within 180 days from date of issuance of such g.#°iU
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.
RECEIPT DATE_ 7 BY DATE FIN ED I INSPE
Signature (Owner/Agent) Date "ti I 7- 0 3
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 Pibg.Test
Final 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
Appliances _
Final
COMMENTS:
Final
Utility Notice(Gas) l
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)