RPL (9911-100)57201 Medinah
9911-100
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
.Ehapter,9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License, is imfulI force and effect.
License # Lic. Class' Exp. Date
574127 A
Date %` Si nature'of:Contractor
,g 4f:
OWNER -BUILDER DECLARATION
i hereby affirm under penalty of perjurythat 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•thisyeason
Date Signature of Owner '
WORKER'S COMPENSATION DECLARATION.
I hereby :affirm under penalty of perjury 'one of the .following,declaratiohs:
(•) 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: '
(This sectionrieed 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 perm'itis issued,
I shall not employ any,person: in any -manner so,as to become subjecf to the
Workers' compensation laws ;of•California,-and agree that if'I should become
subject to the workers' compensation prov islons of Section 3700'of.the Labor
Code, I "shall f rthvyith complyy,with tjaose,Rrovlslops. y
Date: 'r' .7 PPlicant ! > ,%g •'! i°' .""_
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employerto criminal penalties and civil fines up• o $100 000, in
addition to the cost of compensation, damages as provided for in; Sectiorr3706
of the Labor Code; interest and attorney's fees.:
IMPORTANT Application Ishereby made.to the Dire'ctorof Building.,and Safety
for a permit subjecC to the' conditions 'arid restrictions` set• forth on his
application. f
`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 agree's'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 160 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'.. s,peccttiion purposes
Signature' (Owner/Agent)
BUILDING`PERMIT PERMITs# 't _>t
DATE 11112-1.199VALUATION A 35 ,,LOT J v s, • TRACT
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RECEIPT
DATE '
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 Hacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
4S.
Final I I
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
Gas Piping
Gas Test
Appliances
Final2
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)