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LICENSED CONTRACTOR DECLARATION 4.
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 1:1, C A G7 f1312C
Date 1XI-7'" - = Signature of Contractor
OWNER -BUILDER DECLARATION f
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:
Carver Policy No.
SUM FUNE► 14#3906-0
(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:'- , t• , 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 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
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0010-260 TRACT
JOB SITE I APN
ADDRESS
W91.1 :!31F".X.CKFX=. (:;t% DR1VX, 76.9-050-000
OWNER CONTRACTOR/DESIGNER/EN (NEER
d I, av -adi in INC.
1425 E, UNIVAIRBUY' rAM
i✓H01?NDC
USE OF PERMIT
1425 K UNDMIM Y D.MB
AZ 85034 PiROENDC". AZ 6' 034
(60-2)257-1650 C51di 4990
SITD -1ZT 17, PLAN 4R3. PF -RAW .DOME; NOT ,lYSI'.L•>! UDE SLOCK
'NALUPOWSPA OR APPIROMM.. DRIVEWAY. i:4% P1,, 9 (11'IWE VE1*
1�, OLIC710M ;00ISS11,A1=1- OF SAME, PLAN TYPE
Ii63W10rr*ATIG 7'.00 ;sir
OARAOX 43's.0 OF
1ESTMA12a COST 4C r CO1PTSI'nvallolf
165,044.2V
CONSTRUMON I�:L
301 -000 -418 -OW.
MID
PLAN CHECK :WZ
101 -0r..)0 -4.3S-3113
$176.20
MEt;I•I.AWI+CALFEE
101-000,421-000
$60.M)
rQXX,TR1CAi, FEE
101-000-420-000
PLAYMBrNa FU
103-000-419-000
SIV7,00
STSLC.1NO MOTION FEETE • I2231*0
101-000-241-000
$16.50
+ RAPNI}'1'O ViiiY,
1.01-000-423-000
$20.00
1 7 -
.0,11VEJ.0Pfrll.1R�I� ,C.f Iri�_3:
$I,.9tYi.aE1
�x
$3,315.1.80
%D0
940119ko
RECEIPT DATE BY �j �. DATE FINALED I INSPECT7 i�
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 t
Roof Deck
Exhaust Fans
O.K. to Wrap
_
/_�_?. l
`
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls I
Party Wall Insulation
Condensate Lines
Party •Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
o ( BGG
POOLS - SPAS
BLOCKWALL APPROVALS
steel
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
Sewer Connection
_
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice
c3_
(Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Furfures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Certificate of Occupancy
City of La Quinta
Building and Safety Department
This Certificate issued pursuant to the requirements of Section 109 of the Uniform Bui/ding 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
78-911 BRECKENRIDGE DR
Bldg. Permit No.: 0010-260
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: 5-9-01
POST IN A CONSPICUOUS PLACE