0205-258 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
U) 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 '-c-jtt'' 't.
DATE VALUATION LOOT TRACT
cv W Professionals Code, and my License is in full force and effect. O'J2Sls`ytlt. S1if11),00
Q = ch License# Lic.Class Exp.Date
JOB SITE j APN
r~ w 687160 L731 C1()ii'.13 �at3 I ADDRESS 110-953 11.E AVIC.NUI:5,3
Et
i � .t y�r /
Z Date q ;'f L 0+ Signature of Contractor r �/ Y T S OWNER CONTRACTOR/DESIGNER!ENGINEER
QO � / r r 4. 7%L '' .
r` I OWNER BUILDER DECLARATION Hid-I,QI.P,OOi PROPERTIES NATIONAL C019ZTRU017.O14 RF.N'i-F•,L;a i i,I, .
LU W f` I hereby affirm under penalty of perjury that I am exempt from the Contractor's 01.10 MIME 53 14551 A"NDELDRIVE
~ N License Law for the following reason: LA QUJ13+3'1' . (.A. Y27.53 .MI mt'tN HILLS CA Y 1 345
Z ( ) I, as owner of the property, or my employees with wages as their sole (818)2-al-6057 C1I 11 6581
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). ONE 200 AMP SUIT POLE, 17 SPAN PO}.E..`.;
01 () I am exempt under Section , B&P.C.for this reason -
N Date Signature of Owner
ON
a ¢ WORKER'S COMPENSATION DECLARATION --
0 Q cc I hereby affirm under penalty of perjury one of the following declarations: VALUATION 4Piht>U 1.3
r . O ( ) I have and will maintain a certificate of consent to self-insure for workers'
x W IL compensation, as provided for by Section 3700 of the Labor Code, for the
Om —1 - performance of the work for which this permit is issued.
Q U (/) I have and will maintain workers'compensation insurance,as required by
O 0 Q S ion 3700 of the Labor Code, for the performance of the work for which this
a 2H permit is issued. My workers' compensation insurance carrier & policy no. are:
• Z Carrier Ah-gi Policy No. ?1:5()03311fb EsnmATRD COST O1 C:()N&TRUC.'17ON 44xr.ilit
°IUD p PRINTr FRE SUMMARY
< (This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL FEE= 1 C]-000-42O-(XX' xa0.00
( ) 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 thf I shljld become
subject to the workers'compensation provisions of gc at '37 of the Labor
Code,I shall forthwith comply with those pf6v�sio ,f%'
Date: 5/ '/ .; e Applicant lfij Pi7------7-----...'Ipl\f"f:_.
� e , is
Warning: Failure to secure Wor eCompensation coverage is unlawful and
shall subject an employer to crimi r'al penalties and civil fines up to$100,000,in /,jI{addition to the cost of compensation,damages as provided for in Section 3706Qr,
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety LCI—TAILAQUINTA
4 for a permit subject to the conditions and restrictions set forth on his . \ f1NANCEOEPT ,
application.
1.Each person upon whose behalf this application is made&each person at »U14-"1b'}`AL C.1014STRUCTION AND PLAN CI—CI;, c�•-ii1,i.+i.►
whose request and for whose benefit work is performed under or pursuant to
"4441e21 any permit issued as a result of this applicaton agrees to,&shall, indemnity 1-.1303 PRE-PAID Jilin `tl of)
& 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 rERM1fRTI')E vE1 OW 1:39'
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.
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 the"City to enter upon
the above-mentioned property for inspectidn purpo �� /�f RECEIPT DATE BY DAT WALED INSPECTOR
Signature (Owner/Agent) '' `� • tL Date /r q %� `"— — ) - ��
INSPECTION RECORD
OPERATION DATE 1 INSPECTOR OPERATION DATE —1 INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts •
Forms&Footings Ducts
Slab Grade Return Air
Steel Combustion Air
Roof Deck Exhaust Fans
L 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:
•
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole 9 —30— �C>
Underground Conduit _
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
Smoke Detectors
Temp.Use of Power
Final
I Utility Notice(Perri) 5 3 9
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