RPL (9911-066)57171 Medinah
9911-066
4'w °' LICENSED CONTRACTOR DECLARATION '
y 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 # Lia Class.' Exp. Date,,'
ra l ''1 ! 4'!i 4 ' ^--
Date Signat mre of.Contractor ,
-OWNER-BUILDER.DECLARATION
I. hereby affirm under penalty of perjury tkiat I am exempt from the Contractor's
License Law for the following reason: • '
( ) ,11 as owner of the property, or my. employees'with wages as their sole
compensation,:will do the work, and the structure isnot 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).
O I am exempt under Section 5 : , 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 for by, Section 3700`of the Labor Code for7the
performance of the work for which this permit,is issued.
( ) I have and will maintain worker's' 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
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(This section need not be completed if the permit valuation is -for $100.0076r.less),
O I certify that in the performance of the work for"which this permit is issued,
I shall not employany. person in any manner,so as to become subject to;tlie
workers' compensation laws of California,- and agree that if I should become
subject to theworkers' compensation provisions of Section 3700,of the Labor
Code', l s VorthwOrcomplywith' oseProvrslons.'^^
Dater Applicant -
Warning: Failure to secure Workers' Compensation coverage is unlawful 'arid
shall subject an employer to criminal penalties and civil'fines'up to $100,000Jn
addition m
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 applicator agrees to, &'.shall,.indemnify
&'hold harmless'the Cof La Quinta,-its officers; agents and employees.
2. Any permit issued
d as A -result, of this application• becomes null.and void if
work is not commenced withi,i 1'80 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 authorise representatives of this City to enter, upon
the above-mentioned property for inspection purposes.
Signature. (Owner/Ag entp `'" Date
PERMIT #
BUILDING PERMIT
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DATE j — 0/ VALUATION , ;.4 `LOT, .t T _TRACTJOB -
ADDRESS
S 574.718 lA' E D l"4[&J-4
APN
71
OWNER - - - -
CONTRACTOR/DESIGNER/ENGINEER
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RECEIPT
DATE
BYDATE
FINALED
INSPECTOR
C
•u `
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
,ry 077'
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
d
All
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
CK for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
/Z m
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)