0002-086 (RPL)" g LICENSED CONTRACTOR DECLARATION
I her4gi affirr undgr 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
ci i)GNkS E iii . i3G? i3t
:Date 115-DSignature of„C no •tractor„
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
perf81mance of the work for which this permit is issued.
;6I have and will maintain workers' compensation insurance, as required by
6ection 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 iOF
ry. .1 Policy - No. =11701 i�f WJIN.S. COVAPA'
(This section need not be completed if the permit valuation is for $100.00 or less).
O I certify that in the performanceof,tK6ew rk for which this ermit is issued,
I shall not employ any person,in`any mannerso as to beco ,e subject to the
workers' compensation laws of Calii:ia and agrelthajif�should become
subject to the workers' compensafion r•vlslons of�Section 3700 of �e Labor
Code,.l shall forthwith comply,w�'thosprovisions
ID to A plican
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 ori 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 haveread,this application and stat )that the above information is
correct. I agree to comply with all Ci�/nd-State laws relating to the building
Construction, ahereby author�e0epre enta
nd tives of this City to enter upon
the above-mentioned property for/inspection'purposes RECEIPT
r // r
Sig ature'"(Owner/Agent Date ��Ls�
BUILDING PERMIT PERMIT#
(` 1 Elfilfj�_E,�
DATEG% I G( VALUATION LOT LOT TRACT
JOB SITE
ADDRESS 1 7,9-425T 0JUX43A APN F
OWNER CONTRACTOR / DESIIG�gN'��ER / ENGINEER
Yk+•.; k N+tY �..:+, �L`. l -r.
P.0. BOX 810 1425 E. UNIV'r"'RSON DRIVE
L A. QtlJtNTA CA 9M3 P:1' -1'.O1 Mt>: AZ 8-5014 c
(6021257-1656 r'BL #. 4990
USE OF PERMIT
Plai L ANTU OR SPA
PR6,41LASTLik INSPECTION,
VALUAIIIM4 0,000.00 L3
a
HI.tt:lL'6I A I+':Q+,E SilFliiN Ytltfil y .
PLAN QWCK FE -F. 101-000439-318 $76.115
(I +•N1.411 IC,IP' -N FFF 101-000-4.18-000 $1 t7 W
NMC1'ANiCAL FEC --e -POOL 101-000.421-0100 $24.00
NM C1
F'EH -- POOL 101-0W-4210"-1100 945M
PLlli AKNIQ FEE _. POOL 101 -WO -419-0(X) 527.00
S rteMAAL CO NST-W(MON <ANT PT,AN C'1-ikCK
LESS NICE7PAID F E;MS
'3't)i%AL PEMIT ih`EES 1)ilE NOW
DATE I BY. (4( % Vl DATE FINALED
At 9.8 V iY.11ii
5289.0;§
;TOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slib Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Insulation
Compressor
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
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
Final
2 ii _ f
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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r
Owner: RJ7
Homes LLC
P,0' Box 810 f
f
La Qui.nia, CA 92253.
i
46 3rB 1769-460-009-9 79` f Toron a
r : CITY OF LA Q U I N TA RQ•tNSPE SEE Of 130
a BUILDING & SAFETY DEPT. .:,: WIIIBE.0
CLANS 10 CARD A HOu
APPROVED PLA
FOR CONSTRUCTION s
DATE Z BY