RPL (0012-158)79245 Mandarina
0012-158
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
PrvfessiCode, and rpy License is in full force and effect.
Licensel? Lic. Class Exp. Date
Dat6ignature of Contractor{
.OWNER -BUILDER DECLARATION:.
I he affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: r
( ) , 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. 70.44, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project.(Sec. 7044, Business &,Professionals
Code).
O 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.
( &J 'a6e 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.
STAT 9F1;S MAY
(This section need hot 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,
l.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 becom6
subject to the workers' compensation provisions of Section 3700 of the' Labor
Code;
shall forthwith comply with w
hose pros ;n,,
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 property for inspection purposes.
Signature (Owner/Agent)'"" ^ '`r- Date •_'G'x
BUILDING PERMIT PERMIT#
DAT E; VALUATION LOTTRACT
JOB SITE•- `
APN
ADDRESS •,. ,? 1 .t I .ff A t a i
t 6 b•' %••
OWNER
CONTRACTOR IJEESIGNER/ENGINEER
F)T ryrydW LP
lw(l
PO F,0XI 81,E
1425L vN!vr.,--jRaWy kNwy,
LAQUIN'IA. CA 92253
MR)MM AZ 85044
(602)257,4656 ML61 4990
- t
USE OF PERMIT
IWL AWf_`f O.Ift SPA
'POOL. & SPIA, ONLY•ii1..r:A.iaMSIpf dji,RRlE;&S L,itAV,. UP. I'N PLA .'S,AT ROE
4'LAS!`I R. IMIRIMOR KIM EQUINVENT NC1,09l.tRY IS NbT INCLUD l
M THIS PEWIT
POOL A211•:109 SPA :P.a. '
':L' ;t3 t,: ?'r OF c ipt. '°Y rJIT
. .. 11 //..
yy ll''yyppyy •+y y y,F, /'y' , 'i
L 'i1?R.ls"f111.77.0 . /Sf.T17Y,OX Z '
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14,A)l CHECK ME 01 As 50,43. -f3l 8
CONSTtdlOr"710M VEX 101-000-418-000 4 417.(00
MICIE•1,A UCAL'A P -, POOL .. 101.000 -?tri' POOO $74,00
ituc4'•PICA'L, I'b.1+fr. POQI, :. 1.03 -e 00- 4.201-;?bO M5.00
:PLI3MtdMIG FR3, - POOL. 1-011.000-419-000 W1.00
;
!3QJA l TAT MIAMI ,TIt"`° 710114 AND MAN C1MCR
2 4 ,415
RpX-PAM 'Ft+< '3
50100
IWA14 F?ttWIT.D. Z. DUE NOW
RECEIPT
DATE
BY( rw
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
S(fBacks
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final -
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
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- = 1NG &SAFETY DEPT. ARE-INSPEC _
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♦ .108 CARD ARE NOT ON=-
- - _ :R CONSTRUCTION THE SITE; f$iR--SCHEDULED
INSPECTION. i
NO EXCEPTION!
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