9607-023 (AR)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
b21 ! 56 13 cil�Ola7II
Date - Signature of Contractor0..
OWNER-BUILDER DEC*L*-A HATfON�l
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
per 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 & poli y no. are:
Carver a r.+i u er,v4► Policy No. :w+ 5��- r!rrr�
(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 thoseprovisions.
Date: f r Applicant / 1�. tf :
Warning: Failure to secure Workers Gomperisatlon 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
`Rhe above-mentioned property for inspection purposes.
SigQ�0,ire (Owner/Agent
)il` ,,i� ti ;{`tibJ ate 1 itir �1,
BUILDINGPERMIT PERMIT# CONTROL#
3680DATE VALUATION 527,1ilU, }t� LOT TRACT
JOB SITE APN
ADDRESS 5"10 KIN111[ITU 761-461-063
OWNER CONTRACTOR/DESIGNER/ENGINEER
RIC11ARD B & KATt11:1'N f ORDER 1NTEGRM CONSIRUMION
%610 RIVIERA 54705 AVE. CARRANZA
LA QIANTA f.:A 92253 LA Q0191•A Cts 92251
564-5SW (619)504-1274 011114 2068
USE OF PERMIT
RESI13EiN JIM, A1.11ATION
4 .
C1inT041 CC NS'FRt)tJ IoN I 35', .t1) :1*01.'
t°tNU.,oF t'pU;YSrRUCY10N
Wi{,RMIT iN EY ilN1MAkY
Pf.AN (`1fI C K Ff,
1010X0-439-3115
$I761_413
COXIS`3"1 U(:1'1014 FEC.
101 -OW -118-000'
$271.50
fLI1iCHAN1CAL 1111
101. -000-121-0 1
30
S 15A30
ELECf'kf(:AE.t1-F a
101 -OW -4204M)
$27.50
.TPONO AICt'i'tON Ff-M - RES11.)
16)1-000-211.000
V2.7A
D
BS/
RECEIPT
27,9111.311
SUB -TOTAL CON'+tR1 "110N AND PLAN CRECK I $493.26
I I.ESS PRE-PAIDRES
$0.00
JUL 15 1996
DATE
AL P8Ith1fT N'i?&N DUE NOW
BY I DATE FINALED
INSPECTOR
5493.26
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 2y ti0k
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior LathJ 47(l
Drywall - IM. Lath
Final
Final
BLOCKWALL AP ROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
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
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)
i
ii'' -4µ7 _- _ .. F'�'f'�L.i'v :T.„l
PCsA WESTf! RESIDENTIAL ASSOCIATION, INC.
P.C. Box 1282 • La Quinta, CA'92253
May 24, 1996
5736 P01 • JUL .10 '96 08: 24
.✓�r5. iZ hii[ C'i h_Ot��cl'
56 610 Riviera
La Quirita, CA 92253
RE: PGA NXII ST L Residential Association.
a rclaitec�arat .'ai`an�e ` 56 610 Riviera
Dear Mr. & Mrs. Roeder:
Thank you for your submittal o” plans fir a rooru addition at thy: above referenced residence. I
am pleased .to. report that the PGA `kTS T I1 R.esidentiai :Asset iation Architectural Committee
has approved your plans for the room addition as submitted, with the following conditions:
1) Owner°s general"coatractor must interface With the Association. landscape maintenance
contractor, `Dalley Garucning Services, to coordinate the irrigation changes, as a result of the
room addition.
2) Any damaged !L1n' dceape will be; repaired or replaced at owtier's expense. Any new
landscaping needs to be' approved by the committee.
'Thank you for you. suu;aittal, and should you have aoy questions please do not hesitate to
contact me at (619) 360 l61.
Sincerely,
PGA NVEST 1I Rts;dentia' Association
John H. Handel
Association ?1d uiager
cc: Board of Directors
Don.Troy, Art h.itec -ral Comminee Chairman
Notice:
Document Cannot'Be Duplicated
Date 7/10/96
No. 14681 Jurisdiction La Quinta
Owner Name Richard B & Kathryn Roeder
No. 56610 Street Riviera
City La Quinta zip 92253
Tract # Lot # Square Footage
Type of Development Residential Addition
Desert Sands Unified School District
82-879 Highway 111
Indio, CA 92201
619-775-3500
CERTIFICATE OF COMPLIANCE
APN # 761-461-063
Comments
Permit #
Log #
Study Area 106
357
No. of Units 1
At the present time, the Desert Sands Unified School District does not collect fees on garages/carports,
covered patios/walkways, residential additions under 500 square feet, detached accessory structures or
replacement mobilehomes. It has been determined the above-named owner is exempt from paying
school fees at this time due to the following reason:
Residential Addition 500 Sq Feet or Less
EXEMPT
This certifies that school facility fees imposed pursuant to Government Code 53080
in the amount of 0.00 X 357 or $ 0.00
the property listed above and that building permits and/or Certificates of Occupancy for
this square footage in this proposed project may now be issued. , _
Fees Paid By N/A
Name on the check
By Dr. Carol McGrew
Administrator in Charge
Fee collected /exempted by Pauline Pearson Exempt
Signature�,� -Vd
PAX1.1A�Q p,
Telephone 564-1274
r
.r
$0.00
Check No. N/A
Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting