0008-221 (SFD)LICENSED CONTRACTOR DECLARATION
C i I hereby affirm under penalty of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
W^ Professionals Code, and my License is in full force and effect.
O =)�� License # Lic. Class Exp. Date
t- C3u7
w 690645 13 HTC 07/0112(
o Z r-- Dater Signature of Contractor
cc)O�
(
_J OWNER -BUILDER DECLARATION
J
W W I hereby affirm under penalty of perjury that I am exempt frorti [lie Contractor's
~ N License Law for the following reason:
Z_ ( ) 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).
cY)() I am exempt under Section
LO B&P.C. for this reason
N Date Signature of Owner
ON
Q WORKER'S COMPENSATION DECLARATION
p Z I hereby affirm under penalty of perjury one of the following declarations:
Lo � Cr O () 1 have, will maintain a certificate of consent to self insure for workers'
X W LL compensation; as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q () ( ) I have and will maintain workers' compensation insurance, as required by
O U QSection 3700 of the Labor Code, for the performance of the work for which this
LZ permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier MS, COMPANY O T Policy No.
co Z)W DE170041900
C)
J (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
Code, 1- hall forthwith comply with those rovlsions.,7',
Dater % CSD Applicant ..°�
r� e
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 Safetyot"
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 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 State laws relating to the building
construction, and hereby authorize representatives of this City to enter, upon
the above-mentioned properttyyrfor in
,/s
�pection purposes.
`•
Signature (Owner/Agent) ' -"(4(`�'/ &"-Z DateV -rW'Cay
BUILDING PERMIT PERMIT#
///LT
DA• // VALUATION LOT 22'1 TRACTIW
24 25389N4
JOB SITE
ADDRESS -M-05 olma"TdWar. Dion?
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
RM 11QMZ15 7:L..0
PUT I9VWTM3a31r5, DITCr.
]FCD DOX 810
1425 F. LT IWMSI'T'Y DRIVE
LA gJINT,A CA 92253
PHOENIX AZ 85034
(%02pp-11636 MLO 4M
USE OF PERMIT
FAMILYDEq T jN
SPO -LOT M PLAN SA -PERMIT OORS NOF 114CLUDE tR,f,,0C:K''WAJA,S OR
POCiI>.,7SS/o PLAN CH C It".. FEN REDUCTION FOR. MULTIPLE M81JAkdCE OF
SAME PLAN TYPE
CUSTOM CONSTRUCTION 4004',0 SW
Pt' RCHMA`t'IO 43.00 SF'
0ARAOP/CARPORT.(sF 8,46aM
FS"7C.W@.'=:D COST OF CONSr`J(RIMTROM
366,163.50
P, W.rFEE SUMMARY
CONSTRUCTION FEE 3 01 R iO-418-000 5274,00
PI -AN CHECK FEE 101.-000-439-398 $179.93
MECHANICAL 113E 101.000.421-000 5543100
E1.,EC:TRICAL ITT 109.000-420.000 $1311.32
PL'UMB1100 IME 101.000"419000 21".00
STRONG MOTION PEP' -.RZSID 101-000-341-000 $16,62
t71LkbI)40 FEE A01.000.423.000- $20,06
ITIP'1i..ASTRUCTURF,FLT x225=04Cs-443-342 $1,907.00
r'ART IN PUBLIC .PLACES WK 701.000-255.000 S163.42
j0=1 jC
L830 PPR -PAID MRS
UX00
RECEIPT
DATE
I BY
I DATE I AD
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs cfj ALm_
Underground Ducts
Forms 8 Footings 61 fid
Ducts
Slab Grade G ^_
Return Air
Steel
Combustion Air
Roof Deck - -
Exhaust Fans
O.K. to Wrap — Cf}
F.A.U.
FramingCompressor
7z
Insulation_aa(/
Fireplace P.L.
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath - s
Drywall - Int. Lath
_
Final - U 1 _
BLOCKWALL APPROVALS
Final
Steel
POOLS - SPAS
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_ G`�
Sewer Connection' �
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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 d(
Utility Notice (Perm) G-� f
COMMENTS:
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Building Code,
certifying that, at the time of issuance, this structure was in compliance with the various ordinances
of the City regulating building construction or use. For the following:
BUILDING ADDRESS:
Use Classification: SFD
Occupancy Group: R3
78-855 BRECKENRIDGE DR
Bldg. Permit No.: 0008-221
Type of Construction: VN Land Use Zone: RL
Owner of Building: RJT INVESTMENTS INC
Building Official
Address: 1425 E UNIVERSITY DR
City: PHOENIX AZ 85034
By: KIRK KIRKLAND
Date: 4-4-01
POST IN A CONSPICUOUS PLACE