0201-031 (SFD)M
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
,�-"
,Date s Signature of Contractor 'rte
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.
( ,t)"On
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 STAT.19,1?UND Policy No. M1,` 06-0i
(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 ebtlon 3700 of the Labor
Code, I shall fo hwith comply with those provision",,�
aate: Applicant -r`
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and'safety
for a permit subject to the conditions and restrictions,,sQ forth:;on his
application. r
1. Each person upon whose behalf this application is made & each person af'
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees:
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that_the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize represe9ptives of this City to enter,upon
the above-mentioned property for inspecbofrpurposes. `$
Signature (Owner/Agent) i" Date
BUILDING PERMIT PERMIT#
4l?.,i3)1.0 b1
DATE VALUATION SEJ�D,$i�iE<lT0 LOT TRACTJOB SITE
S:Ri
ADDRESS !X %430 C:.�1R:Q)rNO Ptr'.T.L+',t D0 APN 7724404417
4417
OWNER
PO BOX 810
USE OF PERMIT
CONTRACTOR/DESIGNER/ENGINEER
l425 }3v }°:IT.1VlsM�?�. Y DRJV.Ts'
CA. 92,253 PI-101WX AZ 35034,
(607,)257--1656 (3BL % °1990
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WALLS, POOL OR -Mti'.EW1i.Y APPROACH
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101-000.4)8--0013
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WCHANICAL 'FSR
101-000.421.000
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RECEIPT DATEBY DATE FINALED INSPECT
Z5
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
p . - Z
Ducts
Slab Grade
Return Air
Steel
Z
Combustion Air
Roof Deck
./$ -
Exhaust Fans
O.K. to Wrap
%W_
F.A.U.
Framing
Compressor
Insulation
U
_
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
— —d
Final
Final
—
POOLS - SPAS
BLOCKWALL
APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
t -CIA L
O- 2j.-cr=_
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
O2_
Heater Final
Water Piping
Plumbing Top Out
i
Plumbing Final
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection OI_Z p -Z _ _�
Gas Piping
Encapsulation
Gas Test
_
Appliances
_
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring U
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles dr
G.F.I.
Smoke Detectors
Temp. Use of Power
Final 3
Utility Notice (Perm) — -
INSULATION CERTIFICATE
This is to certify that insulation has been installed in conformance with the current energy
regulation, California Administrative Code, Title 24, State of California, in the building located at:
50-030 CAMINO PRIVADO, LOT.99, LA QUINTA, California
CEILINGS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-38
WALLS:
TYPE: BATTS MANUFACTURER: Certainteed Thickness: R-21
GEN L ON CT : RJT H S LICENSE #
B TITLE:L)I
SCHMID BUILDING PRODUCTS, A MASCO COMPANY LICENSE # 632072
TITLE: ADMINISTRATIVE ASSISTANT DATE: 11/13/2003
9
#--QB
BEAVERTON,OR 97007
PHONE: 5035248268
FAX: 503-213-6222
John Hardwick
RJT Homes, LLC
79700 51P Ave ,
LaQuinta, CA 92253
41
RE:
RE: Structural Observation of: Phase 26 /
Lot 99, Lot 100, & Lot 101
John,
Sample observations were made of the above houses to ascertain whether the intent of the
construction documents. is being followed. Of the structural items that remain uncovered and
easily observable, it appears that, in general, there is reasonable compliance with the intent of
the construction documents with no unresolved deficiencies.
Please call with any questions.
Sincerely,
A/AZ//SXV V t
Mike Nelson, PE
b
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