0104-045 (ELEC) LICENSED CONTRACTOR DECLARATION BUILDING PERMIT PERMIT#
CO 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 VALUATION LOT U3.IA.04b TRACT
CNI W Professionals Code,and my License is in full force and effect.
License# Lic.Class Exp.Date 0,114.) I,70t ti., ?0.UU f I.' %•i
N- C APN
JOB SITE
r� (3 r7 ADDRESS
N. W " / Y�°:�5Z 1)31 c10 f.:t„ _.. . oft I/2C 81-997 I f2..Air` NLf 512 - ..
I� r� F �` ,,rr , OWNER CONTRACTOR/DESIGNER/ENGINEER
' Z r- Date S Signature of Contractor f�%/�4._ ( LC,_ �'
Or` _,/
N R.
o OWNER-BUILDER DECLARATION k8d -T,QI I',!LC SR BRAY CORP dba POWER PLUS
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's 81.1 f}O AVE, "i3 750 Al I'1iRl T�iI,V.G�
~ co License Law for the following reason: LA QUANTA CA 92233 PERRIS CA 9257 I
Z_ ( ) I, as owner of the property, or my employees with wages as their sole (909)657-031 C'Fiii 1$81
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 ELECI`RICA1:
Code).
co () I am exempt under Section , B&P.C.for this reason 1 • 100 AMP 7t;MPORAR f POWER POLK
u7
N Date _ Signature of Owner
O �
a WORKER'S COMPENSATION DECLARATION
p I hereby affirm under penalty of perjury one of the following declarations:
r H CC
O ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION LOW Oh L
X W LL compensation, as provided for by Section 3700 of the Labor Code, for the
O J Q performance of the work for which this permit is issued.
CO —1 rJ ,) I have and will maintain workers'compensation insurance,as required by
O U Stion 3700 of the Labor Code, for the performance of the work for which this
ti 1-- permit is issued. My workers' compensation insurance carrier & policy no. are:
't Z Cartier I Policy No. f �r�pp1��,��♦�.���py.����/7(+� �� �}�r y} ` [� 1 R, r,
ob Q ✓'Ti fr `u to i 1:%:1; -I31(1 1V .YMAilD)COST Oar'CONSTROCTIOI'1 .,,Elf',+,+.C�f.1!
(This section need not be completed if the permit valuation is for$100.00 or less). 1<'b`RiI I �`� L+ILI!'dA4='it
I certify that in the performance of the work for which this permit is issued, ELECTRICAL M1 101-000"420"000 $3U.00
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 Labcr—Th /;t 0
1 C e,)shall forthwith comply with those_ provisions.. / , (�
` te: f - 45. - !Applicant f/: #-. -"i (r ( /7V/G l
Warning: Failure to secure Wohkers'Compensation erage is unlawful ant
shall subject an employer to criminal penalties and civil fines up to$100,000,i, APR 6 2001
addition to the cost of compensation,damages as provided for in Section 3706
c;: ip
of the Labor Code,interest and attorney's fees.
IMPORTANT Application Is hereby made to the Director of Building and Safe'y CITY OF LA OUINTA
for a permit subject to the conditions and restrictions set forth on h s FINANCE DEPT
44 application.
1.Each person upon whose behalf this application is made&each person at
whose request and for whose',enefit work is performed under or pursuant to SUB-TOTAL CONSTRUCTION A14D PLAN 1 CT�.CK S30.c 0
"I';** any permit issued as a result of this applicaton agrees to, &shall, indemnify Z.L+f3S PRE-PAID F1 FB $o. 0
& 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 FERMAT FIEES DUE NOW S30,00
' 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 I certify that I have read this application and state that the above information is
t correct./ agree to comply with all City, and State laws relating to the building
constr ctlon, and hereby authorize representatives of this City to enter upon I � (� ��
the at ve mentioned property for inspection purposes. , RECEIPT DATE BY / UATE FIPEALEID- .'t INSPECTOR
- Signature (Owner/Agent) l l y I � T - f 2 Date • -
INSPECTION RECORD
OPERATION I 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 Pl. _ Grills
Fireplace T.O. Fans&Controls
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall-Int.Lath
— -- — —- Final — - --Final I 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 S
Sewer Connection Encapsulation
Gas Piping
Gas Test I
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 b71�1 6�
Final — - -
Utility Notice(Perm)
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