0302-184 (RPL)H
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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
00645 B IP -0. A �C�lt34
Date `�` Signature of Contractor
V r
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&RC. 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.
X(A 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 STATE FUND Policy No. W3006_02
(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 hose provisio�ns�, '
ate:_ `'• .,. ,-� ,ti���
Warning: Failure to secure W IrkeIs' Compensation coverage is unlawful and
shall subject an employer to criAnral 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) -- . e� Date
BUILDMG PERMIT PERMI0302-184
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DATE VALUATION pyyy, LOT TRACT
JOB SITE
ADDRESS .tt.••Jtw�'`.� �.�'��.�Za�.wttn.*C) APN
OWNER CONTRACTOR / DESIGNER / EN INEER
r���/r21k10k"t�gS LLC:�t,rIA:;I�a�ry.�yq��rryM.UJL°t�(n,�r �0.7yY�
PO BOIL 810 144•+5 B, ()WI `f.f.,S�k.1Jyl;6..4 3.+.f,�� ,
JLA.QUIN7A CA 92253 MHCiL'NIX. AZ 8503=i
(6021)257.1656' MIX 4990
USE OF PERMIT
POOL j._'W)10R PWA.
PLACE AT MePLA13TER INSPECTION,
l'ItCI;EJ3iRD.
POOL ,AaV DIOil. SPA
MSISA.1•'ah'.iEM SHALL 5X IN
RQU1PMi~NT 9Plti;".W1 SURY,AsOT
1' ,000,00 LS
RSTM&M COST OF COMMMM110"
prMAir1WX 91711tMtltRY
PLAN CHECK FEE,
i,•GN STRUCT101ki F'E afl'i-f b-+�&%2�-G1 iQ vi.ci�.3i3
ME,C;');i:1 LAICAL FEE •- FOOL 101-000-421-000 32-9.14
91.,F',i TI2ICAL ii`wJr — P00 1 01-00("20-000
00t"20-€100 $td9,f30
PLC4)1 8111"Orte.E •- FQ0L 101y000-419-000. $2700
RECEIPT
R CIAZC.xlw
TOTAL PERAUT FITOMS DUE NOW
r
BY I DATE FI
15,09D.W
00114"0
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
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
Final
Final
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
i
Final
.
COMMENTS:
Final
Utility Notice (Gas) ,
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels +
Exterior Receptacles
G.F.I.
Smoke Detectors -
Temp. Use of Power
Final i
Utility Notice (Perm)
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Page 1 01'2
14712 SW SCHOLLS FERRY
# 328
BEAVERTON, OR 97007
PHONE: 503-524-8268
FAX: 503-213-6222
E-MAIL: minelsonpattbi.com
John Hardwick
RJT Homes, LLC
79700 50� Ave
LaQuinta, CA 92253
RE: Structural Observation of: Acacia Tract 29858-1 Plan P2 Option A
Lot 93 50-135 Camino Privado
John,
A limited sample of observations were made of the above house 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, to the best of my knowledge there are no
deviations or deficiencies that have not been resolved to within reasonable compliance with
the intent of the construction documents.
Please call with any questions.
Sincerely,.
62
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*Jl CN1L
OF CA�1F1
Mike Nelson, PE