RPL (0010-161)79385 Mandarina
0010-161
_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 full force and effect.. .1, -)License # Lic. Class-'-'Exp;Date
Da Q
Signe Y,
of.Contracwoy '
OWNER -BUILDER DE/CLARAT ON ;
I hereby. affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: ' } ' • •
( •) • f, 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).
O I am exempt under Section B&P.C. for this reason
Date Signature of. Owner
- J
WORKER'S COMPENSATION DECLARATION' '
I hereby affirm under penalty of perjury one ofjthe following declarations:
() I have and will maintain a certificate of consent to self -insure for workers'
compensation, as`provided for by Section 37,00 of the Labor Code, for 'the
r 41, ..le .
r p I. rformance 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:
Carrier' Policy No. `-
POND lS 3340fb t t '
(This section need not be. completed if the permit valuation is for $100.00 orless).
( ). I certify that in the performance of the,worklfor which this permit is issued,
y I; shall not employ any. person in any, rrianner/so as to become subject to ttie
workers' compensation laws of California,,and agree that if I should become
subjecvf6 the workers' compensation provisions of Section'37.00 of the Labor
Codd'l shallJorthwith comofv with those [i ovisi ns.
Warning: Failure to secure Workers' Comp nsation coverage is unlawful and
`shall subject ari 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 ;1
fon a permit subject, to ,the conditions -and restrictions set forth on his E.
application: '' '• . .. `
1: Each person upon whose behalf this application_is made & each person at iiJ
' whose request and for whose benefit work is performed under or pursuant to. 't
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 statethat the above information is
correct. I agree to comply with all City;rand.9tatef6ws relating to the building
construction, and hereby.-authoriz,e , - rrepresentatl'ves of this City to enter upony
the'above-mentioned property foviflspection purposes
,a.
Signature. (Owner/Agent) Date_
BUILDING PERMIT PERMIT# 1 '
DATE VALUATION LOT, a ..sa-161 • TRACT
JOB SITE 1
APN .
ADDRESS
+
OWNER
CONTRACTOR / DESIGNER / EN (NEER
t ..
Wa°'.h'iC)lv[MUC
1'2MIMOMM 3klrl
.
14.2:5 F. ZJl IVI stITMY 1YRIVE
1A naDI.NTA, ' '; : CA 92253
KJOI F I AZ 8"34
03Vf 4990
j
USE OF PERMIT
AMOR 910A
—POOL
IAF♦>UL&PA... AI:A11F:11 Wtlib€CC2 E PLALL BE IN PLACE AT PREP-PZ..ASTER '
WSSPEt"♦'t`TO . PC"4 t1.:QUIP1AMT YN(:'i SURF. RD'4,01':INCLUDED. i
POOL N,L?1Ok1 SPA. 1 QOaaf39 L,;:
k . MIKAMD COST OF Cil ro`fi 7CTUM
10IM00
Mal CHACK TREE 101-000-439-310, 3".05
C ONSTRUCT1OW M, 101-000419^000 .. $11700
MrXHANIML FEE -• POOL 101.00064-21-000 $2460,11'
'ft%1rZTfUCW, POOL 101.10W-420-000 $4 .16ti
Pt',i'aNABINGFila,• POOL 103QW419y00
• .ktr
^iCii":4tTCiCayk
AS1'PF:K
99.05s,(
$
A;;. I PRE -:PAM IMM
$0.00
r D •yqA . gyy ffgy pp
DV'
yM1b' -• id.l:b' 1.! i '. rd61'Y.i: .li.' t '.SA l.I . Ql•PY
" ^15 ' or`1
IV
RECEIPT
DATE •?
BY.,p a:r
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Za
Set Backs
Footings
Electric Bond
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
PLUMBING APPROVALS
Gas Piping
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
Gas Piping
Encapsulation
-0
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: