RPL (0012-161)79275 Mandarina
0012-161
LICENSED CONTRACTOR DECLARATION
I hereby affirm-unde'r 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.
'74.ense# = Lic. Class Exp: Date
X90 E5 B HTO A11Qaf3lre{ (
Date_ -'t Signature of Contractor _ M —
OWNER -BUILDER DECLARATION^
I hereby affirm'und'er 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 bo 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).
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 isissued.
( e)•►Whave 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.
(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 irf 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 wit those provi ions.
Date:/,5; -') -;w X_)Applicacl m
Warning: Failure to secure orkers' 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 setforth on his
application.
1. Each person upon.whose behalf this application ismade & 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 riot commenced within 180 days from date• of issuance of such
permit,, or cessation'of work for 180 days will subject -permit to cancellation.
1 certify that l 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 Dat&
BUILDING PERMIT PERMIT#
DATE VALUATION LOT' _ 0012.461. TRACT.
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
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LA QUINTA CA 92IZ53
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USE OF PERMIT-
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PLAVI U, iI` OPFC'!'F0N )700t-, 2,01JIM4,MT AJC#.OSIJ'RY .19 140T f?dt":i UDEb }
IN THIS PKERMIT
POO 1,A2diTaIO SM K096 O 149
X;TrVr.2;` P COST OF Cry .N.SMIM..;d,014 ..
li3aC}dIvU 4339
FR" .' I FY s1C3b. MY
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CONSTRUCTION flFf% Y 01-U00,4 i a-cloo
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RECEIPT
DATE
B,Y1 ,,e
DATE FINA LED
INSPECTOR
' OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set hacks
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
- - UC
Set Backs
Electric Bond
— !j
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Z _-
Underground Plbg. Test
Final I I
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
'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:
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