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LICENSED CONTRACTOR DECLARATION
I hereby 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 # Lic. Class Exp. Date
690645 B IRC A t -;()1$01$2(
Date y f -Qty Signature of Contractor �~�"�� 1/
V
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
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
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 INS COMPANY OF P Policy No. WDEI?00419a0
(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
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I sh I forthwith comply with htth,6de provl Ions.
Date., Applicant—
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 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 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"cancellatiori.
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 propert "for inspection purposes. (r
Signature (Owner/Agent) C� llr�� Date's '
BUILDING PERMIT PERMIT#
DAT -j VALUATION LOT ONS -227 TRACT
jam'lltllt
JOB SIE
APN
ADDRESS 78-8631)1?FGj .NB' 1)G1r D1 I
OWNER
CONTRACTOR / DESIGNER / ENGINEER
Pir 110Tvi0 UIC
Rl°i' x'iMM?ITT S, WC.
PO DOD 810
14,25 1,; t%lIVqMWTY DRIVE
Lik QPWrA CA 92253
AWE= A7 8504
(602)257.1656 CBLA 4990
USE OF PERMIT
SWOLE 1!'.�MD- DW'EUI- 1 G
31rD-LOT 23 PLAN 4A -PER 41T DOPS NOT n%4CLUDE BLOCKWAJ,1, OR
POOL.754/o PLAN CHECK PE1� R"UCTION FOR MULTIPLE ISSUANCE chis
PE
NAME PLAN TYPE
CUSTOM CONSTRUCTION 1,984.00 SF
PORCHIPATIO `77.00 SY
GARAC1Ii/CA11PORT (S 9,466,80
T,SM9:T1 D COS'S OF C0A8: R`U(,7f1+0X
10,044 459
1E.RWi'.Tti'XIE SUM~.' '
CONSTRUCTION PER 101 -000-418-000 "70.50
PLAW CHECK P'LI? 101-000-139-318 $177.70
MECHANICAL FEK 101.000.421-000 560,00
EJ,EC:TRICAS.. FRE 101-000-420-M $136.60
PLUMBING FEE, 191.000-419.000 $15-7100
STRONG x/ OT10?d IEEE - RE5I1D 101-000-241-000 $10.50
GR.AD1NO 611E 101-000-42.3-060 V9.06
INFRASTRUCTURE FEE ` h,5-000-443-342 $1,907.00
�
ART IN PUBLIC PLACES - €tESIL 701.000-255-000 $162,61
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RECEIPT'
,
DATE
BY \
DATE INALE
INSPECTOR
A
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings &72
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck o C<j
Exhaust Fans
0. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines v . Uv
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
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)
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:
Occupancy Group:
SFD
78-863 BRECKENRIDGE DR
Bldg. Permit No.: 0008-227
R3 Type of Construction: VN Land Use Zone: RL
Owner of Building: RJT INVESTMENTS INC
Building Official
Address: 1425 E UNIVERSITY DRIVE
City: PHOENIX AZ 85034
By: KIRK KIRKLAND
Date: 3-21-01
POST IN A CONSPICUOUS PLACE