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RPL (0009-058)57131 Medinah 0009-058 - I LICENSED CONTRACTOR DECLARATION I, hereby affirm under penalty of perjury that I am licensed under provisions of Chapter A(commencing with Section 7000) of Division 3 of the Business and Profe s on91s Code, and my License is in full force and effect. License # Lic. Class Exp. Date 01561.28 C53 10/31/1( te Da. C'01Signature of Contractor 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 STATE FU14I3 Policy No. Ud6-ftQ•OOD61G -0© (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, 14 all forthwith rthwith comply with those provisions. r Date: / ... , CApplicant Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer'to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth -on his application.+ ?,, 1. Each person upon whose behalf this application is made & each persorn• at whose request and for whose benefit work is performed under or pursuant to S any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agent's and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building . construction, and hereby authorize representatives of this City to enter upon 'x the above-mentioned property for inspection purposes. --- '/7-t-_ -L.._ . Si nature (Owner/A ent) Date BUILDING PERMIT PERMIT# DATE VALUATION LOT 0009—ONTRACT /f/ f j"J p. 7 1."'W , dYW.oF bR'V.0.61J JOB SITE APN ADDRESS 57-131 MKIDM R T OWNER CONTRACTOR / DESIGNER / EN (NEER M/M DOM (W M)RtJJL h. ia00 & SPM 57.1 a 1 MMI -14A PI °74-725 JOITI DMVE, #A I AQClxi31`A CA 92253 PIM.M DESKErr CA. 92260 ('760)3. 0.9©00 CBLO 3551- 55:USE USEOF PERMIT POOL, AND/OR SPA SPA &WATERFEATURE ONLY -.Al -4121 1S113ARRI SHALL BE 11.4 PY. ICE AT PRE PLAS IRM NOPECTION. POOL EQUIPMENT ENCLOSURE i$ NO _- 1A1CLUDED 114 111414 PFAtMIT INCLUDED POOLAND!()RVA. 4,900.00 We ; 1111 E91WAM COST OF t"OMM7M10' 1N 4,9W.00 i'Eftli/t U b"FE 9UMMARY PLAN CRECK FEE 101-000-439-318 CONSTRUCTION FEE 101-000-418-000 7z a0 MECHANi.CAL F'E'R - POOL 101.400421.0011 124.00. ELECT Z;CAL FEE - POOL 101-000-420.000 PLUMBING FRE -- POOL 101.000.419-W10 SA09 3UW!'O'I AL AM PLAW ClUC, $214.90 :IMS M-PAIDF= $0100 TOTAL _M 2 MS DUE NOW $21.4.60 1 ,i q - yy . - 10, RECEIPT DATE' BY DATE FINALED INSPECTOR , INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR { BUILDING APPROVALS MECHANICAL APPROVALS S 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 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 O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation / fy/ Gas Piping Gas Test Appliances Final COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Vottage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm)