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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
8 Otitl IWZDf
S ignatu re -of Cont
k,Dat/e ractor-9///&
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 emplo�ees 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. �044, Business & Professionals
Code).
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-.inslure 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.
64)l have and will maintain workers'compensatiori insurance, as required by
Section 3700 of the Labor,Code, for the performance of the work for, Which this
permit is issued. MyWorkers' compensation insurance carrier & policy no. are:
Cartier Policy No.
STAT
. , E FUND 935-9t74230
(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 pircivisioris of Section 3700 of the Labor
I th ."i A �i I
Code, I VAI�fprhwith'comply with osep�evs*7
Z
Applica t
Warning: /Failure to secure Workers' Com ' pensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines . up to $100,006, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMP6RTANT 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
co
-Y§truction, and hereby authorize representatives of thi . s City to enter upon
the above-mentioned property for iQsp�ction purposes.
,/Signature (Owner/Agent) D a ie 1A
PERMIT#
BUILDING PERMIT MIS -033
DATE 081,16f.199VALLIATION $166,169.90 LOT 57 T�ACT
JOB SITE 78-740 GRANOTRAVEME AVIMU11r,
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
RJT r�JVE4,�-rNMNJ-1, tNC.I.
PUT INVEMARN-1-S, INCI
I E. 00,11VTKIM DRIVE
1425 E. UNIVERsa Y bnvu,
PHOUNTX AZ 8_5034
PHOENIX AZ 83034
(6042574656 C81,4 4990
USE OF PERMIT
&INGLEFAMILY rMbLIANG
N7, P1,AN. 1W il�M � ft- KNUT Wl�� K)T LNULUL& HLIUK.X
WM,1. OkPool; 750,� RMUCT10,14 ONPLAN CHECK FFEFORWUTPL�3.
ISSUANCE OF SAME KAN TYPE.
CU�TVONf CO-N81'RUC7101�T ZOM.00 ST"
P0.R(3TV-PAr(0 43.00,WT
0ARAWCARPORT 5F
EST11MA-11.Z COST C* C0NST9VC!FJI0N
PERMIT FEE SIMMARY,
CONCST.RUMOM FRF 101-OW41&OW V
PT, AN CM*CY, K -E 101-600-439-318
MFCHANICAL Me", I smoo
,F_LWM10A'jLFtY,.. 1,01-000-420-00
PLUMBING �M SA66ho
STRON GMMION M - XESID 101-000-241-009
G Pu M N G, F E, S 1011-OW4234ko 3"'0.00
-TI
VVILM PLACTS Rf,4'SW, 7014W-255-000 $165.42
AWr Rq P
D MLOPER IWAICT FEE $1,907m
k7l'
SLIB-TOTAL CONISMUX�FIQN MD PLO] C14ECK
LESS PRE-PAir, FEES
$0.00
ToTm, rrmmn vru", bucNOW
$3,892.61
DATE
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION I
DATE
I INSPECTOR
OPERATION
I , DATE —TINSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
`7-1Y- 1":�
Underground Ducts
Forms & Footings
'T
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
2-0 - c-^'
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_415-7
Compressor
Insulation
1;
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
ot - qrl
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
ShowerPans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
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) ka 4y_ zii_