0002-088 (RPL)-LIC- NSED CONTRACTOR DECLARATION
I.herebyaffirm'•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
• . � L U�l1U�l� °
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l� g
Date Si nature of Contract-
OWNER -BUILDER DECLARATION
t, - } "�
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
perrforma�nce of the work for which this permit is issued.
have and will, maintain workers' compensation insurance, as required by
Ae ttion 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 - Policy No.
r>v;z: � h^er r r. A. .
(This section need not be completed if the permit valuation is for $100:00 or less).
() I certify that in the performance o_f-the,work for -which this permit is issued,
I shall not employ.any person,in`'a any manner so as to become subject to the
workers' compensation laws` f California and. agree that/if I should become
subject to the workers' compensation-praylsion of Section 3700 of tkte Labor
Code ,J,shall fortbwith comply with th-se �provfons
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 . " 5 •
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 160 days from date of issuance of such
permit, or cessation of work for 1i30 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 herebyauthorize repiresenta- ives of this City to enter upon
the above-mentioned°property for inspectio p roses^
#,,•Signature (Owrer/Agent)'3
' . BUILDING PERMIT PERMIT
DATE VALUATION a1t�,i1111i•i� LOT J TRACT
1
JOB SITE
ADDRESS �;�
APN
-O_WNEB.
� f
CONTRACTOR / DESIGNER./ ENGINEER
U i`1`Y3('�q MQ i 1 T• — -T T _ Y
144.A Ai`%4►(2.a,.1 �.dA..•y v 1
1) T i rM1j ry7C.'"'%sq i�T� TY fo
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P.O. RQX 817
`425E 111vN1�1 ST i' DME
LA QUlzi'T'A CA 9225 -4 .
PU )ENM AL W34
(6,02)757-164E (7BL#i- ' 4990
USE OF PERMIT
Pout, ANIXO . SPA
Pt'?v`L S4 SPA OWL i° - AJ AciU4,' iRAId1M-R. SFIALL :BTT PPT PLACF AT
RE-PLASVE' L INIVECTLON. i
4
-
v e+%'t1 ie a'T iJ;v 10,0(10.00 LS
c
E L .I A M 1 u .,0 COST ll `be1'.8t '��..iJ��i1�Y 1l 9y►V''4 $.ION
- MOWN
'FPF,RYi JJT .F;✓•�t.� SUT"AA
PLAN CHECK FEE S76.04
Gc,NSf'1telr_'r1ON FEEF( ,41840)(10
10 VO-"2.-42
LowLv ICr�i. `L��' --.rv`JJ s^vnv -r
F.
ELLCK_ MICAL FEE -- POOL 1.01-000-410-000 $43. 0
P1..+JNDYNG FEE -- [<)OL 101-000-419-0,00 5`1.7.00
S{JB- �)'�t�L:C(�?v'S Tie!{"I`fON ANi�t'i'1.+�?�i�'i1kC�
*28Q,05
LESS PTt.ETAID .LSJ
$0.00
r 'TOTAX, PERMIT I t+ ENN, DUENOW
SZFa�l,05
I
RECEIPT
DATE
BY./'jj}%f,/~`�
�- 1 ll S: 1
DATE FINALED
INSPECTOR
.,.
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 Wail Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
G(/
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
C7<-
UGas
GasPiping
Gas Test
Appliances
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
Utility Notice (Perm)
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Owner: R1T Homes LLC `.
P.O. Box 810 .
La Qui.nta, CA 92253 y
47 3r A 769-460-009-9 '79435 Toronja /
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