RPL (0104-010)79165 Mandarina
0104-010
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.
Llcegse*# Llc. Class Exp. Date
Date !J- +' ` Signature of Contractorr. s "- - ^ ;' r+ ---•w-
OWNER -BUILDER DtCLARATION
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 Labo6.,Code, for the performance of the work for which this
permit is issued. My worke"rs',,compensation insurance carrier & policy no. are:
Carrier r Policy No.
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(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 the Labor
Code, I shall forthwith comply with t ose provisions.
Date: +_ Applicant
Warning: Failure to secure W oke s' Compensation coverage is unlPSaf(E
nd
—.shall subject an employer to criminal penalties and civil fines up to $1n
addition to`the cost of compensation, damages as provided for in Sec 6
,''of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building ay'
for a.permit subject to the conditions and restrictions set fortl I on t is
application.
.,1. -Each person upon whose behalf this application is made & each erson at
whose request and for whose benefit work is performed under or p
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. I agree to comply with all City, and State laws relating to the building
rdconstruction, and hereby authorize representatives of this City to enter upon
.the above-mentioned prope. y for inspection purposes.
Signature (Owner/AgenQ _rl_ Date "
BUILDING PERMIT PERMIT#
DATE / VALUATION LOT' TRACT
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JOB SITE J '" `
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER / EN (NEER
P101 BOX 510.
1425 Z 1.T0.WIz:; r9J,'Y D.TUV1
LA QUWr.A. CA. 92253
Pl1011TDC AZ N`3034
(602)257n10 6 C'%3U- 4990
USE OF PERMIT
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PiiOl srSPA Al ARMVE11'Y. R1US SFEf i•1.1 •L NZ IN Pl,..ACM .kT PR&P1,A5TF R '
MOPECTION. POOL € QUIPMENT ENCLOSURE NOT t43•t°1Xk ZD,
P001tAND= SPA IDIOM cc I X
1 LAR CHICK 'rU 10) -000-439-318 576.05
Ct'NS'MUCTIONFEE 201-0000 418-000 tl`1.Q4S
U0113.AAd3.VIA.L Me -- POOL 101-000-4;2-007 00-421.,.007 $24.00
ift, X,T R1C),\ . PEZ ru POOL, 101-000-42.0-000 00 $45.00
PL-1,11MMO PEE - PCK) ., 101 -000419-000 5770
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PR 5 2001
CITY OF LA OUINTA
FINANCE DEPT
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RECEIPT
DATE/ %
BY
DATE FINALED
INSPECTOR
is 'f 0 E
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
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
POOLS - SPAS
a� —
_
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=�
0
_
Gas Piping
Gas Test
Appliances
Final
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)
COMMENTS:
CITY OF LA QUINTA
BUILDING & SAFETY DEP'.
A P P P OVE
FOR CONSTRUICT
( Com/
DATE
0 4NSPECTlorj
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