9512-078 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm 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
Date Signatureof Contractor
OWNER -BUILDER DECLARATION
I herebpaffirm that I am exempt from the Contractor's License. Law for the
following reason:
( �)/, 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).
O I am exempt under Section B&P;C._for this reason
Date l7 /M/;1-- 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 / Policy No.
(This section need not be completed if.the permit valuation is for $100.00 or less).
(1KI 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: Applicant ��" d:;,• �.� ,.., "'-s�
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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.
Signature (Owner/Agent) i Date
"`°"
BUILDING PERMIT
PERMIT.9512-078
DATE 12,114/95
VALUATION $6,863.7.
LOT TRACT
JOB SITE ADDRESSAPN
31-755 AVE. OBREGIO1
77X163-013
OWNER
CONTRACTOR
Ol'b'NER/BUIL..DER
STEPHEN & LTJCY 1 OSP.EDALES
51755 AVENIDA OBREGON
_0ffX 1e*_ 92x01
C:BL#
% n
DESIGNERIENGINEER
USE OF PERMITOWL AICD/OR SPA
Fi13ERGLASSPOOL5 b A
FEE DESCRIPTION
FEES
CONTRACT AMOUNT 5.000.00 LS
51+ r. WALL 75.00 .LF
4 FT. WALL 1.5.00 'LF
ESTIMATED ED C=. S OF CONSTRUCTION
6,86.3.75
PE1tlrtil IT FRE SU1V1lV@,"Y
PLAN CHECK FIE 1014X)0-439-315 $58.50
CONSTRUCTION FEE 101,-000-415-000 $90.00
MECHANICAL FEE -- POOL: 101-000-421-000 $24.00
ELECTRICAL FIEF, -- POOL 1014100-420-000 $45.00
PLUMBING FFA -- POOL 101 -000419 -MQ $27.00
!> SUB -TOTAL CONSTRUCTION AND PL)\N CHECK.
$244.50
i) LESS PRE -PAID FEES
$0.00
��.. < PERMIT FEES DUENOW
cls 0
5244.50
RECEIPT
BY
DATE FlNALED
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 Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs A
Electric Bond
Footings /t 0
Main Drain
Bond Beam Q/
Approval to Cover
Equipment Location
Underground Electric
/
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
L
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
4.
Final
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:
r
/a- 1,5 - 95-
TiAt 4'4 Quwcu
MEMORANDUM
CASE: ��36& Location(s): CZV � o,,J
Request (9) : /cYo�/� LJf}rZ� �(..� HM'1►.�G ( c.+ {-��-,a -?���to
A%J /
Your setback adjustment application is hereby approved, subject to
the following conditions:
Conditions:
1. Obtain a building permit from the Building and Safety
Department.
2. The other .Zoning Code provisions shall be met.
3. If ground excavation is required, please contact Underground
Service Alert (USA) at 1-800-422-4133. The service is free of
charge provided USA is given at least two working days'
notice.
4. Additional Conditions:
After review it was determined that:
1. This adjustment is consistent with the intent and purpose of
the Zoning Ordinance.
2. There are special circumstances applicable to the property,
including such factors as size., shape, topography, location or
surroundings that justify approval of the adjustment. These
circumstances are:
Thank you for your cooperation.
Attachments
a d:Bu lld ng and safety �DepaMt,,"F—
CITY OF LA QUINTA
PLANNING '& DEVELOPMENT DEPARTMENT
APPLICATION FOR SETBACK ADJUSTMENT
CASE NO:
FEE: $100.00
APPLICANT: Submit this form with two copies of a scaled site plan,
drawn to adequately. depict the nature of the request. A nonrefundable
fee of $100 is-requred when the -Application is submitted. Check must be
make payable to the "City of La Quinta".
If the Applicant is not the owner of. the -property, a letter must be
submitted by the owner authorizing the Applicant to execute this document
in his behalf.
PLEASE PRINT.OR TYPE
APPLICANT/ CONTRACTOR: /Ylc �daL .cn U 14C DATE
CONTACT PERSON (IF DIFFERENT) PHONE
MAILING ADDRESS: SI -
(Address) "(Cityl (State) (Zip)
OWNER'S NAME: PHONE(,� �4--0//�
MAILING ADDRESS: S k - n( �r_- kbr,Vi
s s*
City
State
Q
STREET ADDRESS OF. PROPERTY:'A-�o.N —bEZ(401a�,� [�T��t3
LEGAL DESCRIPTION OF PROPERTY: LOT ,# l D.t [0c_(C 35 TRACT
ASSESSOR'S PARCEL NUMBER: L o�� • 3_S' o S�uti. �,ar wt�I n a�s(�Q we vita
ADJUSTMENT REQUESTED:' fit ore . 51JC.« .1-6 r wct k. We=:�4= 47)JU
REASON FOR . REQUEST :
JUSTIFICATION: No request for a Setback Adjustment shall be granted
unless it is determined' that it is consistent with the intend and purpose
of this Ordinance;. that there are. special circumstances applicable to the
property, including:, such factors asize, shape-, topography, location or
surroundings that justify the approval of the adjustment of the setback
requirement, and that the adjustment will not be detrimental to the
health, safety; and- general welfare ;of, the' •community or be detrimental to
property in the area...0f`the parcel for which'ahe adjustment is requested.
FORM.013/CS
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