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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 # - 4 c. Class Exp. Dal
,)�/ate Sig,nature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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).
( ) 1, 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 Sianature 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" compensatiorf insurance carrier & policy , no. are:
Carrier nATIEI, FUND Policy No.
. . I 013�98_
(This section need not be completed if the permit valuation is for,$100.00 or less).
I certify that in toe 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
C de. I shiplIfy1hwith comply with those pr6vi'2in,
0" . . 5
D A -t e. Applicant—
Warning: �Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employerto 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.
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 Ci * ty 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 dateof 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' spection purposes. I
/)" - r/4
nature (Owner/Agent) Date -
9
1E11IT.J9(1%03(
BUILDING PERMIT
DATE 08/101"VALUATION !91",169.9tJ LOT 60 TRACT ?5_199-3
JOB SITE 50-800 GF-ANDT HAVERSE, AVENUE
—7
PN 169_01�%008
ADDRESS
OWNER
CONTRACTOR DESIGNER / ENGINEER
RJT INIVES-MCNTS, INC.
RJT INVEM4ENTS, INC.
1425 E. bNIVERSUTDRNE
145 F. LNWERSFrf DR[VE
PHOENEX A7. 850.14
P140ENLX AZ 85034
(602)257-1656 CBL# 4990
USE OF PERMIT
SINGLE FAMILY IYAFFELIX.NG
SY0- LIYi� 60, PLAN 14A) OR, :- P'EkM,111' J)0k.3 N(YY I NCL(T
WALE, OR POOL. 75% REI)UCMQN Uty'.TILAN CRELY.. FFF FORINIMITIPLE
ISSUANCE OF SANX PLAN T"130K
C'USTONI C0N3'"tU0n0N 7, 0-s.00 SF
PORCH/"f 10 43.00 SF*
GARAGIEXARPORT 484.0 SF
PEIMIT FEESUNiMARY
IMN,STRUC-110N FrX 10 1.000-4J 84W V370V
VIAX�r C11013CK FEE 101-000-439-318 SS36.2S
MOCHADOCAL M 101-000-421-0-00 $60,00
MICTRICA1. FFF t1.37-32
STROMMOTION FEE - RESSID 101-000-241-000
GRADING MY,.
VRI
, P IN 11MLIC PLACES - W -13M 701-000-255-000
(MMOPF'R IMMM'FrM S.11,907.00,
fT%
'SUB -TOTAL CONSTRUCTiON !\ND FIAN CHECK
.1,$31882.6
LF OS PIZE-PAID FE.U"i
t0l)()
Lk
TOTM, PERMIT FEES DUE NOW
S3,882.61
RECEIPT
DATE
BY
F . INALED
T��C . TOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
lee tz
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Steel
Return Air
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
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Ag e,
Heater Final
Water Piping
Plumbing f inal
Plumbing Top Out
Equipment Enclosure
ShowerPans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
UU14 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) —a Eli, �C)
COMMENTS: