RPL (0104-012)79185 Mandarina
0104-012
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 fulkfo'rce and effect.
License # Lic. Class • Exp. Date
Q 5 F3 a C' d?e 4 Mf.?/dx'2
DateSignature of Contractoprps
i./
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 th&work land 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'
comperisation, 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:
Carver Policy No.
:In'AYXFUN1,J 19131 +6-d3f)
(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 hose provisions"
Date:'r 5« f Applicant
Warning: Failure to secure Wordrs' Compensation coverage is unla d
shall subject an employer to criminal penalties and civil fines up to $100
addition.to the cost of compensation, damages as provided for in Secti
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and fety
for a permit subject to the conditions and restrictions set forth his
application.
1. Each person upon whose behalf this application is made & each pe son at
whose request anis for whose benefit work is performed under or purs ant to
any permit issued as a result of this applicaton agrees to, & shall, in
& hold harmless the City of La Quinta, its off icers;;'agents and employees.
2. Any permit issued as a result of this application.becomes null and void if
work is not commenced within 180 days.'from date of issuance of" such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and 'state that the above information is
correct: I agree to comply with all City, and State laws relating to the building
'%construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
f<
Signature (Owner/Agent)`-- ^` Date!"
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0104.01.2 TRACT
JOB SITE
APN r
ADDRESS 794M MANDAMA
OWNER
CONTRACTOR / DESIGNER / EN (NEER
-
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P101 NYXII. 810
1425 1,3 ummsnry Dvin
L.A Q Y11.1'1.'A CA 92259
PRUENDC A7, 85034
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USE OF PERMIT
POOL AMOR. 4VA
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$NYl}AL pFYwLiIMSHALL & )N ARL7CIP, XC PV-i.d aER
NISI ECTION, NDOL EQUEPUM ENCLOI>1:R NOT 04- C :IJUP'A
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PLKN 01MCK Or"?, 101.000-M-318
COM, .`d' LICTION FRE 101-C?W-418-000
MEACKd- TK; b F"it°l+. - 'P001 1031-NOO-421-000
X)..:,lyd;:TWC;:&LFEF, -POOL 101 -OW -420-000
P1111JU13.INO Merl __ FOOL 101-000-419-0100 ?'7,00
F
APR 5 2001
CITY OF LA OUINTA
FINANCE DEPT b3"1'M'-: k l'R5P',i.KUCHRCK
$289,05
1''t? 'AL lE^.1 14rl1 ':IF°$ .€`XI ''CIF NOW
M%05
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
/
IiI0
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 Wali 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
Underground Plbg. Test
—d
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
.6-1
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:
5- U "
'5-z.
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.
tSmoke Detectors
temp. Use of Power
Final
Utility Notice (Perm)