SFD (0004-305)79395 Mandarina
0004-305
LICENSED CONTRACTOR DECLARATION
I herebyaffirm under penalty of perjury that I am licensed under provisions -of
Chapter, 9 (commencing with Section 7000) of Division`3 of the Business and e
Professionals Code, and my License is in full force and effect.
.License # Lic. Class 1 Exp. Date
6906 41 . B RICA. 046/.30,12(
Date•" -"91p_ '! Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt frorrithe 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 ( ) I, 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
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm -under penalty, of perjury one of the following declarations:
O I have and will maintain a'certificate of consent to self -insure for workers'
compensation, 'as,provided foi•,, 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 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.
1245. Ct7MP N`l a) T WDE170041000
(This section need not be completed if the permit valuation is for $100.00 or less).
() 1.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;)aws of California, and agree that if, I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, L.shallforthwith comply with those provisions.
Date: a . r= Applicant-.•1.t•<`
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. . , • . .!4 . " •
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 inspections purposes.
Signature (Owner/Agent) C» '4,s,! `- Date4T _
, BUILDING -PERMIT PERMIT#
DATE VALUATION: , LOT OW4 305 TRACT
•/yy jj11 ]A} •'
1,tdhJ3•,'"/ fi7.uiY1J 10 3rJ°i"tf-1 .
I 1
JOB SITE 1 +
ADDRESS
APN
79-395 AtiAN,l7AIMA
771,0504M
OWNER -
CONTRACTOR / DESIGNER / EN 1NEER
X13VF; 1it 3'i", , C:
WT 1Nmqrbao1'l, WC.
1425 :E Lslt?1V `?I7'Y 1 I RV '.
1425 L VVIVI—T Z►3` YTT:F RUVE
PHOFIMX t AZ 85034
P710 3: Az 85034
!Ik
(602)257.1656 CrM A 49.90 ,
USE OF PERMIT
SYD-LOT IC PL SRA PERMIT DOES NOT YNC1aL, DE Bl..gcMM.L S OR
POOL,75% PLAN CHECK FEE REDUCTION FOR MULTIPLE N ANCY OF;
SAME PLA14 TYPE
CUSTOM CO1J TRUCTION 48: 3.00 8F
. ;.
POWCKIPATIO 130.00 Sly
(T.ARAOFIC,ARPORT (S3) 11,328.90.
1'w'SI"Jiz4 AT.F 9 COST 07 d. ONr rTIZuC?70N
233,740.M
PERhM VEE S'O M IARY
CONSTRUCTION FRE 101.000.418.000 V1421100
PLAN CHECK FEE 101-000-439-318 $209.36
MECHA14ICAL FEE 201.000*421-000 $93.50
.
FLFA,'TPaC L VK 101-00{?-d?0-000 $155.94
PIMM811140 FEF • 101.000.419.000 $162,50
STRO140 MOTION FEE - R.ES1D 101-000.241-000' CAM
0 RA0IN0 FEE 101.000.42.3.000 $20.00
DEV•ELOPE-q IMPACT FELT $1,907.00
ART IN PUBLIC PLACES-.Fti';S1_I: 701,=000.235-000 194.46
SUB-XIOTAL CON= T3CTTON AND PLAN CrUIECI{
$3,67&84
1T09 FIRS -PAID Fn, ES
$0.00
1•V°r AL k'FIRA ri' I'lu+ .S DU_ E WOW
0§78X4
RECEIPT
DATEBY
/! /
DATE INALED ////
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
f
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 8 Controls
Party Wall InsulationS
v -
Condensate Lines
Party Wall Firewall
Exterior Lath
_ 7_ , as
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
(, j
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: