9908-031 (SFD)M
LICENSED CONTRACTOR DECLARATION,
I hereby affirm under penalty of perjury that I am licensed unde'r 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 # c. Class Exp. DaMv/20(
/Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hprphy affirm Linder penalty of perjury that I am exempt from the Contractor's
License Law for the following reason: e
( ) 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 for
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
p rf rmance of the work for which this permit is issued.
Ri 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 STATEF
UND Policy No.
(This section -need not be completed if the permit valuation is for $100.00 or ' less).
( ) I certil� 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
wor ' kers' compensation laws of California, and agree that if I should become
su6ject to therworkers' compensati6n provisions of Section 3700 (if the Labor
ode, I sTallr bwith comply with.thos,e ' I
L. �
Date: / i YW Applicant A
Warning -./Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,006, 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 thePirector of Building and Safety
for a permit subject to the conditions and restrictions set forth on. his
appli cation.
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 agree s 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
7 co 'struction, and hereby authorize representatives 'of this City to enter upon
e' above- mentioned property.for ins , pection p ' urposes.,
Signature (Owner/Agent) Date VA/
PERMIT1909,031
33 2S
DATE VALUATION LOT TRACT
JOB SITE M934 ISK AA-MMMA)GE KAKIVIII;
APN
ADDRESS
OWNER
CONTRACTOR / DESIGNER ENGINEER
RJT INVESIVENTS, INC.
RJT MVEMIENTS. INC.
1425 E. VNIVEMM r!'PFVT
14-25 E. UNIVERSITY DRIVE
PHOENIX AZ 85034
RHOMIX AZ 850-34
(602,)257-1656 CBL.# 49".
USE OF PERMIT
SINOLE FAMILY DWELLING
SFU- 1,01- 53, I'LIKIN Wo 7K .. pf"I'l ut PIL)f INILUJUE !WCK
WALL CIR POC)L, 75% REMUCTTOIN ON,.FkL,-^%N CHECK FFE FOR N9JLT rpf-rl
ISSUAINCE 0F SAAM PLAN TYPE.
"110
C133T014 CON&rfktir IN 1,984.00 8F
PoRcHipAno 77.00 8F
GARAGMARPORT 483-N) SP
RVI171KATED COST OF CONS111"UCTION
165,11M4.54
PERM,ff FEE STAINIARY
CQNSTRUCrION V"F.E 1101 -000 -418 -WO 1870-50
MANCHFICKFEL 101-000.4,39-31,3 S&13.11
N=HAMCAL VEE 1101-000-421-000 S60.01).
&X(�TWCAL FR. 101 -MI -420 -WO
PLUM,OINCT FEE 1,014416-419-" S157.00
sTRONQ MarION FEE - RM. D 101-000-241-000
GRAD[NOY FEE uaoo
AWI'M PUeLIC PLACE 8 . Rh—Sir, 701 -00-2 55-900
0F,VFJ,0P6,t MPACr FEW
J
SUB-IOTAI, CONSTRUC� flON AND PLAN CHECK
$3,803.32
3
LE&S PRE-PAIDRIES
$0,00
TOTAI, PERrUff FUS DITE NOW
RECEIPT
DATE
BY (A
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE -TINSPECTCiR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
ExhaustFans
OX to Wrap
F.A.U.
Framing
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath 77- �2 zff
Drywall - Int. Lath
Final
I Cl zl�
Final
BLOCKWALL APPROVALS
Steel
POOLS -SPAS
SetBacks
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cov"er
Equipment Location
Underground Electric
I
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
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL. APPROVALS
Temp. Power Pole
Underground Conduit.
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
E)derior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final C-7 He -
Utility Notice (Perm) /_ - _S- CU
COMMENTS: