9908-030 (SFD)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.. L Exp. D%et,�0/_20i
fic. Class
2 645
9, Y 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:
( ) 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 fo e
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 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.
ooI 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 & pqlicy no: are:
Carrier SrATE FUND Policy No. 05-566.1230
(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,
l,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 orthwith comply with those pro I idn
Date: 0�12? A plicant—
T p
\/WarningdFailure 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 & eac h person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this 4pplicaton agrees to, & sha - 11, -indemnify
& ' �holcl harmless the City of La Quin,ta, its officers, agents and employees.
2. Any permit issued as a result of this applicatio n becomes null -and void if
work is not 'commenced within 1.80 days from date of issuance ' of such
permit, Pr cessation of work for 180 days will subject permit to cancellation.
I certify that'i have read this application and state thatthe 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 in�pection purposes.
7
\�ignature (Owner/Agent) Dat�
PER"T'4909-030
9-3
,,JU1LD1NG,,F,,A19,M1T
DATE VALUATION LOT TRACT
JOB SITE 78--T46 1111-REMENWHIM;, DRIVE
APN
ADDRESS
OWNER
CONTRACTOR DESIGNER ENGINEER
RJT INVESTMENTS, INC.
Xrr INVESIMEWIS, INC.
1425 E. UNTWAMTPIUVE'
14-2 5 & U, 1.NFR.S rl'Y'D IUVE,
PHOENtX jsLZ 8.V34'
PHOENIX AZ 85034
(602)257_16% CBLP 49N)
USE OF PERMIT
SINGLE FAMILYOWELLMG
ph-ftff:T mma.
did fte
WALL M P00t.
CLISTO&I CONSIRUCTION I.M.00 SF
P40R.Ok-5)KNO 7_70) 8F
GARAGMICARPORT 419�-00 8F
ESTIMATED COST OF CONSTRUCCION
10044.50
Pmmyx r -Eh s umm-ARv
CONSIMUCTION M S870,30
PLA14,Cl EECK FFM %79).81
S60.00
UE.WfRICAL FEE
'PLUMBYNG PER $157.00
C
TFRCXING MOVOIN FUE RESID I[OHN-241-WO
GPJUX N0 FEE 120.00
ART [NIPUIAMPLA-CM3, 9X31r, 701-000-2-515-000 $162.61
,D WFIOPER IMPACt PEE SLW7-00
WO -1M AL. C0NfSMLV1101N jVW D PLAN CfXCK
LE.'S3 PRE -PAID FEES
S0.00
TOTAI, VCRAHT FEES DUE NOW
S4.041.42
RECEIPT
DATE
I
B
YL.
DA -if F!PALED
[INEPECTO R
1
I
CkA9 3
INSPECTION RECORD
OPERATION
DATE
T
INSPECTOR
OPERATION
DATE —TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
10*4:::_�_
Underground Ducts
Forms & Footings
V-0 _// Z
Ducts
Slab Grade
I
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Fireplace P.L.
Vents
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
'Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
72 7�
Encapsulation
Gas Piping
Gas Test
2--3 e, -d
Appliances
Final
Final S- czv A�C_�
Utility Notice (Gas) z:-4.r�� Au�=
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Vottage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final C�-d
Utility Notice (Perm)
COMMENTS: