0403-184 (ELEC) LICENSED CONTRACTOR DECLARATION PERMIT* J
rn I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
I— Chapter 9(commencingwith Section 7000)of Division 3 of the Business and 0403-184
aP DATE VALUATION LOT TRACT
cN w Professionals Code,and my License is in full force and effect. 03Lt0/7(X SI;200 cxl 21.22 2)383e-4
p n ch License* Lic.Class Exp.Date
n W L n I 77Li99 li 04/3Io/2( ADDRESS S y:-3191/7 MOUNTAIN VIEW. APN 762-420-022
'' Z I- Date>-I"- �-r Signature of Contractor'- L�`•�I OWNER CONTRACTOR/DESIGNER/ENGINEER
O ,--
~ OWNER-BUILDER DECLARATION TOLL BROTH) RS INC TOLL(3RCYTFTER2 TNC
uu LU ^ I hereby affirm under penalty of perjury that I am exempt from the Contractor's 7l-121 TIRED WARTNC3#100 73-)2) PRLI)WARING/i)00
~ License Law for the following reason: PALM DESERT CA 92260 PALM DESERT ca 92260
Z ( ) I, as owner of the property, or my employees with wages as their sole (750)674.9699 CDL# 3 83 2.
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 FT FCI fi1f F3
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
m () I am exempt under Section
inB&P.C.for this reason IRRIGATION PE.Df+STAJ.,. 7001 CPC.
N Date Signature of Owner
O a
d 'C WORKER'S COMPENSATION DECLARATION
oQ c I hereby affirm under penalty of perjury one of the following declarations:
I— O ( ) I have and will maintain a certificate of consent to self-insure for workers' VALUATION 6200.00 U
X w L1 compensation, as provided for by Section 3700 of the Labor Code, for the
Om - 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 c Section 3700 of the Labor Code, for the performance of the work for which this
CI: rn F- permit is issued. My workers' compensation insurance caner & policy no. are:
co`r 5Z Carter LIBERTY MUTUALF. Policy No. WA262D0 0 4 72 301 2T1 ESTIMATED COST OF CONSTRUCTION i,200.00
N- O PERMIT FEE SUMMARY
(This section need not be completed if the permit valuation is for$100.00 or less). ELECTRICAL-PEDESTAL )0I.000420-000 t3).50
( ) 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 �l
subject to the workers' compensation provisions of Section 3700 of the Labor D
1A(N U
3 code, I shall forthwith comply with tho eg provisions.
/'Date: .' o,re-F• Applicant = --
Warning: Failure to secure Workers'Compensation coverage is unlawful and _ MAR 11 2004 J
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 CITY OF LA QUINTA
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
firapplication.
1.Each person upon whose behalf this application is made&each person at SUB-TOTAL C10N8fRUY 7IO.N AND P( fiCd':`ffECK r33 SU
whose request and for whose benefit work is performed under or pursuant to I.F 99 PRE-PAAD FFEZ1 30 00
ic:11 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 TOTAL.PERMfF FEEN DUE NOW t33.N
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 this City to enter upon
the above-mentioned property for inspection purposes. RECEIPT DATE-- , , BY •'�` DATE FINALED INSPECTOR
'Signature (Owner/Agent) -�--� Date I
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 Flrewall
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
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(Penn)