SFD (0004-302)79445 Mandarina
0004-302
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.
License # Lic. Class Exp. Date
690645 B FIT A. 0613012(
Date4' `- Signature of Contractor p "
J
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
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:
( ) 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.
( ) 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 INS, COMPANY OF T Policy No. WIR17004:1900
(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
1 Code, I shall forthwith comply with t se provisions.
1 pate: t -` _i Applicant—
Warning:
(/Warning: Failure to secure Workers' Compe' sation 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) 1 ., 1 iif a , ✓,- Date tg ^'►
i 1
V) 'BUILDING PERMIT PERMIT#
4-d
ON4 '30 2
DATE VALUATION LOT TRACT 28447-1
523;4,i4 i
JOB SITEAPN
y
ADDRESS ti"`o`R5 MAMARYPA
772-d#4£ 003i
OWNER
CONTRACTOR / DESIGNER / EN (NEER
M IN VIZ a'!'It?f,I Trs,1, c.
PUTT I% IEST..1Niwr 5, raC.
1425 L 7DRIVMMTY A1?.7V.1:
1425 Z UNIVER3STIT DStM
MOWW AZ 85034.
PHODIDC AZ 85034
(602)257.1656 CBIA 4990
t
USE OF PERMIT
MGM 17AMMY MMI"(3
SFa.LOT 5 P1.3R.R PEIRMIT DOES NOT INCLUDE SLOCK.WAL•LS 09
POOLM% PLAN CHECK NEE REDUCTION FOR .MUL'T'IPLE ISSUANCE OF
SAME P1J%a4 TYPE.
C:USTO,N! CONSTRUCTION 2,831011 V
P RCEYPA.TIO 130.00 SF
101ARACRUCARPORT (SV) 11,328.80
1
EFTOAAM COST € -W CO1.MNTIR. W CTT0H
213,749.50
COIMST UCTION PER, 101.000-418-000 $1108.59
PLAN CHECK FEE $226.30
MEC8, i11CALFEE 101-000-421-000 $105.00
RLECTWCAL FEE 101-000-420-000 $169.22
PLUMBINO FEIN 101.000-419.000 S180.50
STRONO MOTION FF - P.ESID 101-000-2, 41-000 $23.3'
412AD1 40 FEF; 101.-000.423.000 $20.0
E)EVELO.PFA IMPACT FET; $1,967,00
ART 114 PUBLIC; PL.ACF.3 - RWE 701.000.2.55.0041 SK46
SIL-TOTAL CONS711.1.1C7' ON AND PLAN C"t CX
$3,823.55
9 MPd ID, MIS
$0.00
`.1TMAL PY-Mr f'1' F,8 DATE NOW
RECEIPT
DATE
BY/ `
f
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Q1
Underground Ducts
Forms & Footings
Ducts
Slab Grade
vp
Return Air
Steel
„
Combustion Air
Roof Deck
—'AAr
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
_
Compressor
Insulation
iG
Vents
Fireplace P.L.
Grills
Fireplace T.O.
'
Fans & Controls
Party Wall Insulation
Condensate Lines -
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath_
_
QED ii
Final
_
Final ! _
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIN. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines%2
Water Piping
G(/ `/r l f
Heater Final
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: