RPL (0104-009)79155 Mandarina
0104-009
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.
Licenses#y ty la pLic..{Class Exp. Date y0
102
Date ` - " ' •`;f 4 Signature of Contractor.
OWNER -BUILDER DECLARATION
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
performance'of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 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 Policy No.
MATE FU14D
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensatpn provisions of Section 3.700 of the Labor
..COde,:t shall forthwith comply wit those provision$
~`'Date: q!tt —sal Applicant ftt:.."r+w:..
r
Warning: Failure to secure Workers' Compensation coverage is unl u nd
shall subject an employer to criminal penalties and civil fines up to $1 I
addition to the cost of compensation, damages as provided for in Se 7 6
of the Labor Code, interest and attorney's fees. ,
IMPORTANT Application is hereby made to the Director of Building n Saf ty
for apermit subject to the conditions and restrictions set fo hon is
application.
1. Each person upon whose behalf this application is made & eac person at
whose request and for whose benefit work is performed under or
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
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. l 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 prope for inspection purposes.
Signature (Owner/Agent) •„ `'""'°` Datell- ^0l
BUILDING PERMIT PERMIT#
DATE r'l f VALUATION LOT LJ804_(W TRACT
JOB SITE
ADDRESS
APN
719-31545 ,bIA.iSTDAR,i1tiTA
77M"4
OWNER
CONTRACTOR / DESIGNER / EN 1NEER 1
P101 Dox 610
14-25 R, 1TN13.rFk'TrYDMVR'
LA (,?URd".EA CA • 92253
FIT-1:C3EUM AL 85034
(6'02)x57.1656 MAN 4•990
USE OF PERMIT
POOL A1 -173/0R SY A
P001,da^PA, dt.7.F1kUfS1€3Ai ii;.dEMS SHALL NE IN PLACE AT FPM-PLA.y'TPR
IN SPEC'MON, POO, L &QUIPMDU .f~'NCLOSURK NOT T.XCrXf1. Fu).
k'OG.LAN1"NOR SPA
E' TRIIIA D CO Mir Ct) 'fi".I.'i'il'C '.k C .% i•
1Lfaed i E:1
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i
CONSTRUCTION FE -9 101-000-4.13 84*)
MMUMCM, RE . POOL 101.000-421.000 SUM
EI..I".C'1 TICAL M -- POOL 101 -000-4,20-000 S4a: ,00
PLLpRM.'a FRE ,.. pool, 101-000-41R-000 sn oo
Q 0
PR - 52001
ITY OF LA QUINTA
FINANCE DEPT x"s Al, CONS'],` ': YL'.1C7W D PLAN CHECK
M=;PRF,-PAZFM1
$010.3
'AMAL FERNUX VAES DIVE NOW
d
RECEIPT
DATE% BY
DATE FINALED
INSPECTOR
t. f '• , .. .Y _
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
Set Backs
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
;Z�:
Final
Underground Plbg. Test
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
G
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. Co of Power
Final
Utility Notice (Perm)
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
DATE ' --
"31dlr,t w,tt
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A RE -INSPECTION FEE OF $30
WILL BE CHARGED IF THE APPROVED J
PLANS AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDULED
INSPECTION.
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