0202-240 (ELEC) LICENSED CONTRACTOR DECLARATION PERMITS
rn I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
I— Chapter 9(commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT WV) /fit) TRACT
eV co Professionals Code,and my License is in full force and effect. IY.tJZ2ftUC 3i`.`�O.IIU
o D el License# Uc.Class Exp.Date
JOB SITE APN
r W 7_ ADDRESS
r n 7�l"its�(1 ft 7 l:i'•di2( 79-.'S3811.2 RIMS AVENL1E
oZ n ' Date• -21' n JZ Signature of Contractor - "1 .,�0�I_ OWNER CONTRACTOR/DESIGNER/ENGINEER
(D t L"�`i
J U OWNER-BUILDER DECLARATION WOW)DEVELOPMENT,INC WORLD DEVELOPMENT,INC
LLI Lu n I hereby affirm under penalty of perjury that I am exempt from the Contractor's 74.3331]WY]]i if1• 103 74•333 HWY 1] { FTlE 101
I— a License Law for the following reason: CA 92260 PALM DESERT C f1 s'2260
PALM DESERT
Z ( ) I, as ownern, of the property,, or employees with wages or their sole (760)568-2955 CRLil 502E
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
contractors to construct the project (Sec. 7044, Business & Professionals ElEC RICAL
Code).
() I am exempt under Section B&P.C.for this reasonIn INRIUATION PEDESTAL
N Date Signature of Owner
rn
a z WORKER'S COMPENSATION DECLARATION
o 2 , I hereby affirm under penalty of perjury one of the following declarations:
(n F p ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION 'ISO DO 1,1
x Lu u- compensation, as provided for by Section 3700 of the Labor Code, for the
0 J Q performance of the work for which this permit Is issued.
Q U (\ iI have and will maintain workers'compensation insurance,as required by
p U Se do 3700 of the Labor Code, for the performance of the work for which this
cC le) I— permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier Policy No.
th 5 STATE FUND 1509393-99 ESTIMATED COST OF CONSTRUCTION 7 0.0 1
Q (This section need not be completed if the permit valuation is for$100.00 or less).
PERMIT VICE SUMMARY
J ( ) I certify that in the performance of the work for which this permit is issued, ELECTRICAL-PEDESTAL 101-000.420.000 533,511
I shall not employ any person in any manner so as to become subject to the . • 2i
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 s alt fo,rthwith comply with those provisions. �f �/,
Date:2 7 :,Applicant >,:1?Fi�,` "7v " (� u t�
•
Warnln(�: Failure to secure Workers'Compensation coverage is unlawful and 71;
shall subject an employer to criminal penalties and civil fines up to$100,000,in •
f!!�{
addition to the cost of compensation,damages as provided for in Section 3706
d U F
of the Labor Code,interest and attomey's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety ' ' r ti.
L C OPIp{QU0
for a permit subject to the conditions and restrictions set forth on his
r. MA0.rtr_p
application.
itir
1.Each person upon whose behalf this application is made a each person at
to
whose request and for whose benefit work Is performed under or pursuant to 8[1B-1'O AL CONSTRUCTION AND PLAN CHECK x:(.i 50
ics any permit issued as a result of this applicaton agrees to,&shall,Indemnify ISM pISi•pAilS FEj?,9 $0,00
& 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 $3'{ ]
work is not commenced within 180 days from date of issuance of such
tpermit,or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above Information Is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon �.; Cy ''mod �� fir
the above-mentioned property for inspection purpose$. / RECEIPT DATE BTE FINALED INSPECTOR
Signature (Owner/Agent) % Date/I"`i'II"
1
INSPECTION RECORD
OPERATION DATE INSPECTOR OPERATION DATE I 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 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:
LFinai
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)
0Zs0Z'7-1/4" 7438"
MONTE LEE POST
C� SR.CIVIL ENGINEER
"A STEP ABOVE THE REST'
p WORLD
i c E V E L O P M E N T
i44, _L2I3 RLS-03564 OC
N 760/54$244 DIRER 74-333 Highway 111,#103
� 760/568-2955 OFFICE Palm Desert,CA 92260
N w CUSTOMER IN: A10' 760/6741421 FAX www.world-development.com
C1 — CJ61r- � ni post@world-development.com
I \o , LID IN: 1/0 AL TRI. 120/240V "1
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CONDUIT NOTES:
A. INSTALL 1-2" CND. SCH. 40 PVC
PER SHOWN LENGTH.
A INSTALL 1-4" CND. SCH. 40 PVC N.T.S.
PER SHOWN LENGTH. T,SS, R.7E, SEC2OK
PROJECT:P-2857 NW14007726 C.S.P.g2302 SHEET 2 0F4
DWG. SHEET IMPERIAL IRRIGATION DISTRICT
REV. CHART DWERIAL. CA
'4:20'1 COACHELLA VAUEY DIVJS10N
Call: TOLL FREE UNDERGROUND DISTRIBUTION
I 1-B00 LICKED DEVELOPMENT INC.
422-4133 44-990 1/2 DUNE PALMS. 3A QUINTA 1
II) TWO WORKING Days CONDUIT/WIRING JOB 4
WOK YOU DIO
t DALE: REV.I BY: '. DE901: R.KamaWm* I?
DRANK; J.LEN OATS: O1/25/2002 CHECKED BY: APPRO U .t QMYSJ
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