RPL (0105-025)57121 Medinah
0105-025
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
Date:%_ _A,/-"--49'
-Sig ature of Contracto`r.'
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).
( ) 1, 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 Policy No.
EXk%I d '1".ION ON FIL
(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 sous to become subject to the
workers' compensation laws of California, and agree'that if ,I, should become
Rsubject to the workers' compensation provisions of Se'ctio6700 of the Cab
Code, I shall forthwith comply with those provisions..
Date., : r• .-, .i'Applicant .. _ . ✓`
Warning: Failure to secure Workers' Compensation coverage i"s,,unlawful an
shall subject an employer to criminal penalties and civil fines up to $100,0
addition to the cost of compensation, damages as provided for in Section
of the Labor Code, interest'and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and S I y
for a permit subject to the conditions and restrictions set forth or is
application.
1. Each person upon whose behalf this application is made & each pers n at
whose request and for whose'lenefit work is performed under or pursu t to
any permit issued as a result of this applicaton agrees to, & shall, inde nify.
& hold harmless the City of La Quinta, its officers, agents and emplo
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 inspedtion'purposes. ✓;:-,
Signature (Owner/Agent) r %' r / 0" = Dated
BUILDING PERMIT PERMIT#
-^"
DATE f ,t f VALUATION LOT TRACT
TRACT
JOB SITE
APN
ADDRESS
57-121 AIRDWAR
OWNER
CONTRACTOR / DESIGNER / EN (NEER
7.111 ) M R4AH
I0-1at3niu ?1r Rom#3
LA Q.L7'i0'.rA CA 922:53
RANIC'HOAMIAM, r_1A 92270
(760)931-L1 60 CBW :W35
USE OF PERMIT
V1"dt9d. SFA. €17.kF'lR;tFaJYI)i•. J1RIERS S1,!•1• IW, BEEN PLACFV AT M&CLf'8S3"a R
WSRC:TION•. P00LK.tU1PMFNT lMCl:,OW991ttO?' JNty3.Af,1MD. 6 -6-
P01011 ANDKI)R SPA 5:..
xsrrDmvrFD con, we consmucnoN
PM MIT FSX KIU'MW. rely
PLAN 0"11=91; c, 101=000.4.39-318 S206105
c ; r f,;r 's r T ':rt> . tta• -s t- .p - arar a.4
.111HIG11.1INWA VVIIi. -_ Pool., 101-W, 0.421-.000 324.0
"-PLi}@40i!NOlE'XF,.-- POO4 1 91-. _ R $27.0
ul
Lit I
MAY 1 6 2001
1
M AY 1 6 2001
CITY OF LA QUINT,q
FINANCE DEPT- a
CITY OF LA U_1_ JA ~:f 9'1A1.s !6N91! R.,
FINANCE DEPT . IMS PFM WW 1*'FO;,0
3:'+)TAJ.n I138ff ° rM )DTM NOW
9619,0°+
RECEIPT
DATE „ ` f f
BY
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
Set Backs
—Electric Bond
,c _
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Dnderground Electric
" Underground Plbg. Test
Final
_ Gas Piping—
-
PLUMBING APPROVALS
—r-as 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
Cc
Gas
Gas Piping
Gas Test
Appliances
Final
00-1
6—s
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)