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RPL (0012-154)79195 Mandarina 0012-154 LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provision§ of Chapter 9 (commencing with. Section 7000) of Division 3 of the Business and Professional Code; and my License is in full force and effect. License # Lic. Class Exp. Date 6906 4-3 13 ino. Date's -pop 60 Signature of Contractor OWNER-BUILDER ' 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). ( ) 1, 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- pate eason Date Signature of. Owner WORKER'S.COMPENSATION DECLARATION I hereby affirm under penalty of,perjury one of.the 'following declaration's: (.) 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 requiredby 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. STATE FUM. 19 39©6 -RU e (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' compensa ion provisions of Section 3700 of'the Labor Code ,L hall orthwith comply with t ose pr vlslr a Date Applicant' `'. -,-- ` Warning: Failure to secure Workers' Compensation 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.. 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 application. 1. Each person upon :whose behalf this application is made & each person at whose request and for whose benefit work is performed under or.pursuant to 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 construction, and hereby authorize representatives of this City to enter upon the above-mentioned prope y for insp tion purposes. Signature (Owner/Agent)'`---.: Date BUILDING PERMIT PERMIT# DATE/,; /,' -, VALUATION LOT ,' rS.. TRACT ( ' y JOB SITE ADDRESS APN' 7 1." .T4±d 3, '.$9, 11V't d 7dr ryI 6Kl' OWNER CONTRACTOR / DESIGNER / ENGINEER WT 110 O ;T, lbs`. 7 J ' 3 Ci iibff d`i' 0 71 SCu. Y.A. QUJN-TA CA 92253 PR(.Yf4NJ fi: AZ X50^,dt (60 )257-165 , CRU, 4990 USE OF PERMIT POOL Al IND/01Z MIA P001w rS2'.SOA 074L?..-AL.A11Mti l.Ar,' .lFh',S' :iAALI, HF, IIN F'GA °,'. .61T PR9 ' N.,rtiMIX MMS'$'MON POO1, EQUIFNI.KAt'T rKNC14S1.TRR 18 NOT I MGI.Lb17L D IN `iHf.r" PFht lT. T P00f, ANDD R "INA 106000,00 a`v"3 fiJt D5W CONT T O CO.Mr3Ts",tTNXIMON P.R"aw.r91MMB"R •` Pv• ryY.. ' 4 CHECK kl1r, • 103 -000- 3S3 -*33 > - 3'Y .:f► .. . . 137RI)COON FEZ 101-000-418-000. MSCRANICAL FEE -- POOH 101.000-421-000 R%,WTRICAL FEF oe POOL, .. #0i-t1t 0 -420 -Qt) PLUMBING FW. K -IOL' '101-000-419-000 iUD? TOTAL COldSWIMPM .A ND.l1✓'x,W CHEM $1199.0 7.; US s PRE-k'AU) JTFS $0.00 TOTAL,'PER1V 'DAY , YUM/ =9105 RECEIPT DATE By DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Shit 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 steel POOLS - SPAS Set Hacks Electric Bond ' Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric 4 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 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) Final COMMENTS: . ' 2~~ - ^ ^ -F LA dUINTA- BUILQIRG & SAFETY DEPT. nu ccc 'ME SITE OR A SCHEDUL MOM / / /