CP (0010-167)79325 Mandarina
0010-167
LICENSED CONTRACTOR DECLARATION
thereby affirm under penalty of perjury that I am licensed under provisions of
yChapfer 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 " Ys, Exp!Date
„Fate - _ Signature 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
r
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
p rf?, AA, " ce of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by
Se`ction 3700 of the Labor Code, for the performance of the work for which this
permit is Iissued. My workers' compensation 'insurance carrier & policy no. are:
Carrier Policy No. yy G. 2 2.pp• / •!!r3
(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,manne jso as'to become subject to the
workers' compensation laws of California,+:and agreerthat if I should become
subject to the workers'.. compensation prow sions/of'Section 3700 of the Labor
Code, I shal orthwith comply with;those'provis`l S. * -•
,;,Date:/.Z,T X Applicant ,' , ids i ^ : - •—.: «. » .. .
Warning: Failure to secure W54kers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and cidil.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 ;3
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 -'St to laws relating to the building
construction, and hereby,authorize„representatives of this City to enter upon
the above-mentioned property fqr inspection p rf'oses.
•I ignature (Ownerf-AgentA '>' ° Date//d `XII
BUILDING PERMIT PERMIT#
DATE dd VALUATION LOT , ” TRACT
I t-,, S"i4ti1=000
JOB SITE t.
ADDRESS
APN I
`OWNER
CONTRACTOR / DESIGNER / EN (NEER
P.0, 33M, W Q
3 425 X VMMM Y' DItii A3, r..
-CA • 92253
11HC5M4W AZ 850.94
(O.2gZa1CSOMT0
USE OF PERMIT
PO (X, ANWOR fTA.
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cost Off!° Cd,9a". EnRu ;` 0s
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Plan X C=HECK fM 101-000-439-318 $76.03
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K,i CTRU;CAL E - POOL. .101 -000-4,20-000 &siS:00
l?LUMN01 freek -- POOL 101-000-419-000
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RECEIP
DATE j
BY
DATE FINALED
INSPECTOR
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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
Drywill - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
!
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
�f
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
F/2
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
Final
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COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
FROI RJT—HOMES FAX NO. 7605646505 Oct. 17.2000 02:59PM P14 1 "i
.0ty of La Quinta 1
BuIldIng K Safety DIvIslon
..................
...............
P.O. Box 1504, 78,495 Calle Tamplco
j La QuInta, CA 92253 - (619) 777.70'12
Building Permit Application and Tracking Sheet
Hill
._:M 014 --?0Y, W -4 O'Wncf'3 N&mc.:'RJT Homes; LLC
77.2,-06 0'.. 05 Address, PO Box 810
City,ST, Zip: Le Quinta, CA 92253
RJT investments, Inc.
v P60) 564-6555
Telephone:
-------------------
14?5 E. University Dr. 'Project Description:
219 Phoenix, AZ 85034
(602) 257,1650
690645 City Lic, 0: 4990
Z!. Designer.
Construction Typo: 40w,'k Occupancy:
Project type circle one _W _WAdd'n mw Rcpb.:
Pcfson:Ch2d Meyer Sq, Ft.; 0 Stories: 9 Ujnit5
:--:,r-CP%!,0fContac) Person: (760)564-6555
Bstimalcd Value or project:
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FROM RJT_HOMES FAX N0. 7605646505 Oct. 17 2000 03:00PM P15i ff
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