9908-182 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 700b) of Division 3 of the Business and
Proiessionals Code, and my License is in full force and effect.
License bc. Class E.p. Da
/ate gnature oVContractor_-4e-
OWNER-BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason'.
( ) 1, 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 her eby 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
sedt16n 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.
SLATIR FUND ., 013.548-1230 1 1
(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 issuedi
I shall not employ any person in any manner so as. to become subject to the
workers' compensation laws of CaYfornia-,apcl agree that.if-ilshould become
subject to the workers' compensa tion provvyons of,Section 3700 of the Labor
Code, lls all focthwilhpomply,with those ovisiol
Date: 17APPZ�nt
iz
Warning: Failure to secure Workers' Compensation -coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 37.06
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Direct . or of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application ismade &'e6ch.person at
whose request and for -whose benefit work is performed under or.'pursuant to
any permit issued as.a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of L a Quinta,, its officers, agents and employees.
Any,permit issued as a result of this application be6omes null and void if
work -is not commenced within, '1180 days from date of issuance of such
permit, or cessation of work for 180 days will subject'permit to cancellation.
I certify-,that.1 have read this application and state that the above information is
correct. I agree to comply With all City, and State laws relating -to the building
construction, and hereby authdfte repr6sphtatives of, this City to enter Upon
the above- mentionk pr6i�erty fop4n'spectio-n' purposes.
I tz�
Signature (Own'bzgeq, Date
BUILDING?,., PEF;MIT4%S_ASZ
'AIT
&4qf
DATE VALUATION LOT TRACT
JOB �ITE 7115- WAD UAN A 1X4 P.IN XS 1,11 lit V lk�
APN
ADDRESS
-OWNER
CONTRACTOR DESIGNER ENGINEER
RJTH.0iNfE$, LLC
RMNWS-MENTS, INC,
PO'BOX8101
1425 F A-MVERSITY DR.1VE
LA QUINTA CA (,W.53
PHOENIX A Z 11,15 0 3, 4
(602)257.16,56 CUP 4990
USE OF PERMIT
POOL AND/OR SPA
KX)L &,� SPA- Lit', IN PLACL, At' Fft
INSPliMNON,
POOL ANWO'k SPA. 1%()00.,00 I's
CSIINATED COST OF CONSIT RUMON,
PERMIT FEE SIMIRMAY
PLAN CHUCK FIM.
07NSTRLICTION FER
MECHANICAL FRE - PUX 1,01 -000421 -OW
'ELECTRICAL FAM - _P 1 00% 101-M-4,70-000 %4' .00
MIN4131 NGFRE - - P001, 401-OW4194M *27,00
n
L D
r"J
'TJ
'SICIf3�.,41)()TAL CON" �,11()N _I�Nj) PL�V CHI" C
"K
$289.05
L'F,7�S TREE -PAID FVXS
11WAL PERMIT FEES DUR NOW
/,L47
RECEIPT
DATE
BY
DATE-PINAL7
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
I I
I
Final
I
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Set Backs
Steel
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
g: Z3 -
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
V1
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
Final
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)