0301-150 (RPL)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
C53 Inc #11113 1 /ol
Dated +" Signature of Contractor �11A..,
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
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 tliis'
permit is 'issued. My workers' compensation insurance carrier & policy no. are:
Carrier COMP)D;,rIATI Policy No. ¢46.6168.3073
(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:' :� -, p !t Applicant{`
s+' .vim^ ✓
Warning: Failure to secure Workers' Compensation cove ge 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 authoriz�•r�presentatives of this City to enter upon
the above-mentioned propertyforilnspection'purpoosses.
Signature (Owner/Agent) '� " .. Date '
F II PERMIT#
PERMIT r: e®
19011l�'�ING -1
I
DATE , .,„, UATION �'sgq y"ry�y� LOT
1 TRACT
a � o VAL+� i � �..r..Utb
!
JOB SITE
ADDRESS S*.,,7175 MINIMA
APN
OWNER pu
4
CONTRACTOR/DESIGNER/EN (NEER
3004 °lATELAM
�::A:CrV+CRNIAPOOLS & SPAS CMP MAN CO
.44:751UV1�':7Ui
S&I Ot) A 54
LA 0,UWA Crit 92253
C OACHE'LLA CA 922:36
(760')398-9 '12 ;C111114 003551
USE OF PERMIT
P0OL BARD 011, -011PA
I'orl.OLy SRN 10 LF, 41 Ptd OC:K'WALI, CITY S"Y'ANOMta).
ALARM OA. RIR-45 20t( A, BE IN PLACE AT PRE.-Pt.ASTER t23SPI=~C d JGH,
41,T `it ALL Ifl,flr7 I4F
f?Or9L Atd'171C+iZ SPA I i Mom .La
r� %M#`;END C(? ' OP C,:OMMUCY102T
PLAN CHECK FRE 101-000.439.318
C ONS7'1;. IDTION ME. 1.137.-OI3(I~+51 •�3`�34I Q &x.00
MW1-iANIIC:AL ' ;-flt3c� .a-000
s ^ ? •F ,f? :OLS„ ] �U ?Ca-C30C " D.at1
. JHiv 1 � LUU3 ,
OF �OUINIA
CITY DEPT.
FINANCE
i
VS -INS PRA -PAID IMS
•s
TE UE
MT-ALPOWU 1! 14; D X6
RECEIPT
DATE
BY
DA E F
IN PEC 0
z
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
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs I j
Electric Bond
Footings Zak 0 3Main
Drain
Bond Beam 3 3
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
j 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 _f3�
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lona Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Cz
Temp. Use of Power
Final
Utility Notice (Perm)
SENT BY: PGA -WEST RESIDENTIAL ASSOC, I; 760 771 5125; JAN -7-03 il:40AM,• PAGE 1/1'
PGAWEST
RESIDENTIAL ASSOCIATION, INC.
January 2, 2003
John and Jail 1'atllam ,'
54-275 Riviera ,;...
La Quinta, CA 92253
Dear Mr. and Mrs. Tatham:
Mr. Don Adolph Architectural Committee Chairman, has approved your- request to install a new
prx)l, spa, decking and landscaping at your 54-275 Riviera residence. Any electrical wiring exposed
during construction must be reported to the Homeowners' Association immediately. Upon
completion please submit the enclosed Notice of Ccimpletioil fonn to this office.
We reserve the right to make a final inspection of this change to inake sure that it`inatches
original request. An approval -is based only on the aesthetics of your proposed plan and should not
be taken as any certification as to the construction worthiness or structural integrity of the proposed
change.
We appreciate your cooperation in submitting this request for approval. If l may be of further..
assistance, please contact me at the HOA office, (760) 771-1234 extension 15.
Sincerely,
K cGalliard
Operations Manager
cc: Architectural Committee
Enclosure
4
P.O. Box 1060, La Quinta, California 92253, Telephone 760-7,,71-1234 FAX 760-771-5125