RPL (0012-162)79285 Mandarina
0012-162
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I ani licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Prof F Y`jonals Code and my License is in full force and effect.
w,.
License W Lic. Class Exp. Date
690643 13 TLi ,A. y 06/3 WAC.
t F`
Date • " '61gnature of Contractor's 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 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
Coale):
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 e
will maintain a certificate of consent to self -insure workers'
compensation, as provided for by Section .3700, of- the . Labor Code, fo'r the
performance of the work for which this permit is issued.
(6p''f have and will maintain workers' compensation insurance,' as required by
Section 3700 of the Labor Codeofor the performance of the work for which .this
permit is issued. My workers' compensation insurance ' carrier & 'policy, no:are:
Carrier Policy No"
STATE YOUND
(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, 1 hall orthwith comply with hose provis ns.
Date: l ' Applicant.*j40 4. 0 a—
Warning: Failure to secure W(rkers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $f00,o00, 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 io 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 for inspection purposes. •' ' "
► . Sy %'amrGi
Signature (Owner/Agent) Date r'
BUILDING PERMIT PERMITk
DATE ,,, f /,/,, /+
VALUATION LOT 001 ",621 TRACT
r'
X111
JOB SITE
APN
ADDRESS 79-=5 114AIWATUMA
OWNER
CONTRACTOR / DESIGNER / ENGINEER
1425 E U91WAMT D %6.:'
x..•AQU04`1'A. CA 921:5.3
PH0ENi'C: Az ssC)44
(f02)a5' .1656 M4 4990 .
USE OF PERMIT
POOL AND/OR aPA
POOLBE J14 l"L,CI:AT PI.M'
PLARTYX INSP8 Tt:ON .T1001, EQU1PNf,,9XT FMCLOSLYRF !S NOT . CL:;v1ixi o
IN THIS PERMIT
IT
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POOL ANDIOR. M. AMAMI L9
.. 7 ' , : V. d3'.f' ID C;® r' C);4 '. •'S)k !'w ; A U' .k J
- l,f °i„fli?
I'l.Al C;f fl<G`l F'1tY 101-000-439-318,
CONSTRUCTION TREE 10 a _000.418_00 5 'fit i'7 (to
A4WH MICIAL FIE - Pool, 101-000,421-000 sx as
) ) ..C7"fiTt,.I4.l P} r• C+t7L . ._ ;. • -9 61x- JC+i}-4 4-1 C34D $Fi;..t10
P3..i1MBNO $'M-° POOL 201•-000419.000 U7,00
uL1;-lit A7 tu0A1a3 $C"°L° r_?3ti9ldk k'Ri! " C`iC.
'; :495
l ii+3ai F'F L ' t3la €fa
$0,00
TC►:k'n. IV
?.d9t' 5 DUE SAO
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RECEIPT
DATE
BYE/.r ?/'
f. I.
DATE FINALED
INSPECTOR
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
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
r
Set racks
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
Q.K. for Finish Plaster
Sewer Lateral
Pool Cover.
Sewer Connection
Encapsulation
—
Gas Piping r
Gas Test
Appliances
Final
— (j
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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