0006-026 (RPL)U)
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LICcNSED 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 DATE
Professionals Code, and my License is in full force and effect.
License # Lic. Class - "'— ExD. Date'
690645 B HIC:'A11.
Date Signature of Conti tor,
.--" s
°'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.
( ) 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 INS. COMPANY OF T Policy No. it DE1 70041900
Jhis,§eEtion need not be completed if the permit valuation is for $100.00 or less).
(i I certify that in the performance of the work for which this permit is issued,
I all' not employ any person in any manner so as to become subject to the
workers' compensation laws of California;'and agee tha if I should become
subject to the workers' compensation provisio o s cf ection 3700 of the Labor
Code, I 'fiall orth I ..comply.,with those pro�ons.
Date: rL-`�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.
I. Each person upon whose behalf this application is made & each person at
wliose 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,, cessation of work for 180 days will subject permit to cancellation.
BUILDING PERMIT
) VALUATION LOT
..✓ Slt),�it3,tii#
JOB SITE
ADDRESS 52_780 Cypr,,=S 1Pon%r
x
RXr Ik1VE3'TW.N'T'S, INC.
)425 R tM ' `T Y" DRIVE
1-114MUK AZ 85034
USE OF PERMIT
POOH... AND/OR SPA
PERMIT #
-026 TRACT
APN
CONTRACTOR/DESIGNER/ENGINEER
RJT WJ139MEM INC
1425 I; I.1NIMM S ;r DIGTS?
{
P110k= AZ 956-14
(602)257.1656 ML # 4990
POOL $ SPA ONLY- AI ARNIS1Il.Jitti:.IBRIS SHALL BE l'1.2' PLACE -AT
PRE -PIASTER IAISPrXTION, BLOCK WALL Frig .F,,QUIPM"EN T ZNCWSUI:B
IS NOT MCLUDED TPI THIS PERMIT
VALUATION
10.000.00 Lo
>":9,E'.ldXrED COST Ol, CO.IVS'T'T2lu'C'nos
YKE 9'ti;1r MUZY
PLAN CHLC K 1ZE 101-000-439-318 SW105
CONSTRUCTION .FEL 101 .000-4.18-000 $117.00
MECHANICAL IEE -- POOL 101-000-421.000 $24.00
GLf1:C IFTUCAL PRE .. POOL. 101-000-120-000 $45.00
PLUMMO FEE -• POOL 101.000-419-000 "2109
I certify that I have read this application and•state that the above information is
correct. I agree to comply Iw th all�`City,,an�State laws relating to the building z
construction, and hereby au�t,hori a*representatives of this City to enter upon
the above-mentioned prope , y�fof inspedlion purposes. RECEIPT
Signature (Ownsr'/Agent) Date
ST.1"1i-TOTAL Cfi9S'r1MUCT109 AND PLM C:EiE',CK
DATE
4
TOTAL ]t MM FEES DUX TKOW
DATE FINALED I INSPECTOR
10,000A)D
$284.05
$0.00
$389.05
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Final
Underground Plbg. Test
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
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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A RE -INSPECTION' FEE OF $30
WILL BE CHARGED IF THE APPROVED
PM AND JOB CARD ARE NOT ON
THE SITE FOR A SCHEDUM
VNECDOIL
.No
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