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0303-152 (ELEC) LICENSED CONTRACTOR DECLARATION , cCO BUILDING PERMIT PERMITM I hereby affirm under penalty of perjury that I am licensed under provisions of I- Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE ♦J VALUATION LOT " TRACT CV CO Professionals Code,and my License Is in full force and effect. OJ/12/2f/. S600..00 O D el License# Uc.Class Exp.Date R. 0 r JOB SITE 52359G MART CIOC61 0J/31/),( ADDRESS 78-t18112 AVENIIIA I.A.FONDAAPN N- i OWNER CONTRACTOR/DESIGNER/EN�,INEER ZZ CD 0 r- Date 2 71 ti,. Signature of Contra j,(}'�C f — --J U 0 OWNER-BUILDER DECLARATION MARVIN HOMES ITTc BRAY CORP dba POWER PLUS W wa I hereby affirm under penalty of perjury that I am exempt from the Contractor's 78-03(1 CALLE ESTAI)O#201 275011.PER J)RJ3 BLV co License Law for the following reason: IA QUINTA CA 92253 PFRRIS CA 92371 Z ( ) I, as owner of the property, or my employees with wages as their sole (909)057-0431 C BL.# 1 Fi6 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 to construct the project (Sec. 7044, Business & Professionals Code). 1200 AMP TEMP POWER PCILF () I am exempt under Section B&P.C.for this reason N Date Signature of Owner OO) d Q WORKER'S COMPENSATION DECLARATION p 2 Z I hereby affirm under penalty of perjury one of the following declarations: H p ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION 600.00 La X w LL compensation, as provided for by Section 3700 of the Labor Code, for the O - Q performance of the work for which this permit Is Issued. m Q U ( ) I have and will maintain workers'compensation insurance,as required by Q Section 3700 of the Labor Code, for the performance of the work for which this Il La;) Fa- permit Is Issued. My workers' compensation insurance carrier & policy no. are: . Z Cartier SLATE 1°UNI? Policy No. 1555110.010 ESTIMATED COST OP CONSTRUCTION £dx'r.n0 co 0 N- a PERMLTPa:WITMMARY 5 (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEL 10l-000-420-000 S30.o0 ( ) 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 of the Labor Code,I sh II forth ith comply with those provisions. / A Date: :��� Applicant • Warnln : Fall re to secure Workers' Compensation cover8ge Is unlawful and 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 • I of the Labor Code,Interest and attomey's fees. IMPORTANT Application Is hereby made to the Director of Building and Safety irfor a permit subject to the conditions and restrictions set forth on his application. 1.Each person upon whose behalf this application is made&each person at BU -TO1.AL CONSTRUCC{ON AND PLAN CHECK whose request and for whose benefit work is performed under or pursuant toIts LF�I l PRE-PP,7U Fli1i 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 D a a II "�44,PERMITFEES DUE NOW! work Is not commenced within 180 days from date of Issuance of such J 'I 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 MAR 1 3 ZOOS J • 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 CITY OF LA QUINTA the above-mentioned property-for inspection purposes. RECEIPT FIN UtVJ. BY DATE FINALED INSPECTOR Signature (Owner/Agent) ' Date.. - /,' , , .. V. f�� - 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 F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans 8 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 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 -`__r 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. 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