RPL (0207-216)77760 Calle Madrid
0207-216
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter.,9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
48:3340 B M-1 ^ - 2 x;01.
e -Date 411 r 0 Signature of Contr for
OWNER -BUILDER bECf 6RAT ON
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
perform ance,of'the work for which this permit is issued.
1=have and will maintain workers' compensation insurance, as required by
Se i'
on 3700 of the Labor Code, for the performance of the work for which this,
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier i##TfiATZ, F"-M;D Policy No. 11602.97.01
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) 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
subject to the workers' compensation provisions of Section 3700 of !he Labor
Code, I shall fortwith comply with those rovalons.
Date:Z'"' 10,Applicant
Warning: aij re to secure WoftlrsCo pia sation coverage 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
of the Labor Code, interest and attorney's fees. U
IMPORTANT Application is hereby made to the Director of Building ra'nq'Sa (qty
for a permit subject to the conditions and restrictions set forth on l Is
application.
1. Each person upon whose behalf this application is made & each pares n at
whose request and for whose benefit work is performed under or pur5ua, t to
any permit issued as a result of this applicaton agrees to, &'shall,.ndemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null a "void if
work is not commenced within 180 days from date of issuance f^.such
permit, or cessation of work for 180 days will subject permit to cant;ellatiom
i
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.
,, ^;. "" craw^
Signature (Owner/Agerft)r._... 646 Date a l ' .%
BUILDING PERMIT PERMIT#
0207-216.
DATE a` VALUATION LOT TRACT
JOB, SITE'
ADDRESS 77-760 C ,AAaE& AM=J
APN F
OWNER
CONTRACTOR / DESIGNER / EN (NEER
IMaKE,
231 X .ALM' .f .€")RO BLVD #, #34
78 120 C ., : ` AT>0
MV:ERXIM, CIA. ?2-11001
LA QtJaaMA CA .922".1
'
(760)777-8120 CZVf 3.224
4.
i.
USE OF PERMIT
MAI"D/0A SIM
PODUSF'A.ALARMSJ,CiAPME.RS SHALL BF, IN P1 AZI? AT 4`'i!ti.,-P1.A1STK
INSP n:O OIC 1"QUIPMUT MC;LOSUtCE1• NOT tk CLUB LED
VALL ATWN 1!000.00 LIJ
E ',9.'lfiIATY.D C09f O: ' C CNSTRUML?N
1 z 11C17 4
pwi M ECK FEE 101.000^4'339.318. MUM
CONSTRC+Ci'10H FN'E 101-000.4194*0 $163.0)
MEECHANIC.AI, FEE -- POOL 101.000.421.000 524,00
EL EC'!' ICAL T EIP, — P61YL 1 in -E' o -42o.0.04 $=19.00
TILUNI r 0 I'VE o. f►0to 101•.000-,09.000 IIrl.00
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DATE FI 'A
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INSPECTOR
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C ALLE'D
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INSPECTION RECORD
OPERATION
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 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
2
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
30L16 Z—
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 (Perm)