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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
69065: 13 SCC (P101112
Date/!,1— 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
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 - Policy No.
STATE FURD
(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 shall forthwith comply with those provisions.
Date: .r : �^; . ,. Applicant 6 J /r. ,
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 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 inspection purposes.
Signature (Owner/Agent)
Date /,: -, —w�
BUILDING PERMIT PERMIT#
DATE f VALUATION LOT TRACT
t i b. �a- .- • $165.044.-V,6 14 25389.
JOB SITE
APN
ADDRESS
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��7^YOflr`lY{/6i
OWNER
CONTRACTOR/DESIGNER/EN INEER
PUT :t
. I N !1yM M.11 TS, 1111..
y�l'��ryfy� �?'-A�Jry"1}"�v,�IRC.. Lys
1425 ER, Se�:;YA'T:3,M3 .Y..G R � I
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P110ENI 69 95034
1�'.4 OE A AL 85034
<,602)257.1656 CK4 4990
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USE
gO``((F��PEERjtMIT �� �� +��, �{fiygg +y{/ �i [fig q y ���ry
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WAL P001 1#.PA OR APPROA01i DRIV FWAY,
CIF5110fa CONSTRUCTION 11994-00 SP
P4)Pt".I^rlP.SATIO �rjp.SfO SF
OAF., G& 483.00 8F
IT -0W- 'FAR SUMMARY
w1NSARWC1ION 7ZE, 301 _000-41 8 -wo S8110ts(I
P1::,d N CHECK Flup, 101.000-429-318 31
TAE '1W1IC,AL FEE 101-000-421-000 $60.00
101-000.,120-1043 $112,6D
I'
WILUMBINO VII?13 101.000-419.000
:7'1`1 IX00 MOTION FEE'- RESID 101.000-•241-000 $16.50
GRANNO FEE 101-00 0-4-23-0010 i0 $20,00
Tali''•+YL-OlaSRIMPACT PLE $1,907.W
SIk/J7'"f08AL COMM A JeS:ON A^1D AJL%.N CMM
1AIM PRF -PAID 10M
Moo
RECEIPT
DATEBY
{�
Dfj�E F
(0 Q
INSPECTOR
cs.
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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 if - 67- G`
'
Final
Final (o'l_S - U( I /2
BLOCKWALL. APPROVALS
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test t �(4
Appliances
Final
_
Final
Utility Notice (Gas) l f
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
GY.I.
Smoke Detectors '
Temp. Use of Power
Final l5 _
Utility Notice (Perm)
COMMENTS:
y
(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: 78-890 BRECKENRIDGE DR
Use Classification: SFD Bldg.. Permit No.: 0010-257
Occupancy.Group: _ R3 Type of Construction: VN and Use Zone: RL
Owner of Building: RJT INVESTMENTS INC
1.►-d�trt
Building Official
Address: 1425 E. UNIVERSITY DR
City: PHOENIX AZ 85034
By: KIRK KIRKLAND i
Date: 6-15-01
POST IN A CONSPICUOUS PLACE