0401-119 (SFD)y :f, 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
690645 B WC A t _ 6!a WX
'Datef - °`3 'f ' i� Signature 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:
( ) 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). y.
O 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 STATE FUND Policy No. 1533906-Q1
(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 provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.'
Date:
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.
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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for,,inspection purposes.
h
Signature (Owner/Agent) -% '�� �%` �Date/ 7L
BUILDING PERMIT • PERMIT#
• 0401-10
DATE VALUATION LOT TRACT
•I ell . i r? CS2,M 41.;9J 3CP 29818_2
/'
JOB SITEr . , .. ;
ADDRESS - 7"M
APN
OWNER
CONTRACTOR/ DESIGNER/ EN (NEER
I?S� IfiC1 a l i1
14251 UNIVRAMT MM,
1_4Ql'WTt% C.A. , 92253
PROIENIK AZ tSOM
(602)25-Y - 165 6 . CHIA 4,990
USE OF PERMIT
`aF+4'3 .. LOT 30, VLAVN SF250. I'=41`t' P3sJXS NOT INCLUDE POO),
SPAS, By=K tKY.!#X,.M OR DRIVEEWAY.APPPLOACH
TPACT CaNST UCTION .-4,3&t0e a'F
£��Oliir,H/�P TIO '' '�a
�839.�00y CS17?
1�.1,'Al•W1VJJ.:d��eft.iY.TIO - PA100 ail' ! r
;,,yyy111maxilrD C 0113 .' OF co.w ' UMM'm
CONSTRUC 1611ME 1 01.0 O4i s=OOO $1,210.00
PLAN GhlEt~ K FEE '101-000-439-S1R $1,037.33
MECHANICAL FRE . 101-000.421.000
ELECTRICAL FEE 101-0100-420-000 $?A9.7B
PLUN1BINO FEB 101.000.4.19.000 $289,00
STRt,33!1'OMOTION FEE - R1121D 101-000-241-000 $26.26
GRADING FrX4 '101-000-423-000
DEVrELt'3I'ER IMPACT FEW,
ART IN PUBLIC PLACES - .1ZE81E 270.000-445.000 $156.45
ST.TI'-Tt7$'.F+L t; CA2�7:;�3��1.3CT1:OW AHD PLAIN C7t3:"[: K
$5,538.76
LFAS
TMAI .:t`�I.t�.' YET, DUE NOW
JAN 28 1004
a
C I FAV• 0:" Bun, eu."p�•I?
FFISIANCE DEPT.
RECEIPT
DATE }
BY /
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
?Q'- -
Ducts
/
Slab -grade
Return Air
AZ
Steel
-�J,. -
Combustion Air
Roof Deck
—
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
y
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wali Firewall
Exterior Lath
._
Drywall - Int. Lath
--
Final
�iy
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 �J
j _ ,, <
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Sewer Connection
.., Q -
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas) `-
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring e
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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This Certificate is issued `pulrsuant toy the requirements sof Section y109 --of the California Building
Coale, ,'`cern �n that; at . the �4time of issuance, 'i this structure ; was fin.` compliance `rwith ;the ,,
fy' g -
provisions of ;the BuildingCode and the various'- ordinances 4�,of the � City regulating. building.
construction and/or use.,,,-.
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BUILDING ADDRESS 797525 VIA SIN CUIDADO a
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Use'classification -.S.F.D. �- t '''� MA ing'Perinit No 0401-119 -
�_
Occupancy Group: R-3. -Type of�;Construction:-`V-N; _ Land Use Zone: R -L'
Owner of Building:,RJT HOMES LLC' `=a ' ' ' Address: PO, 130k 810-
'.' City; ST, ZIP: LA QUINTA C ;
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�F. = By: G.•SHOWALTER
r L1 '✓ �� r .• r �,. yDate: '11/09/04
.`
Building Official
1.
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POST INA CONSPICUOUS PLACE,'