0101-177 (MISC - TT) LICENSED CONTRACTOR DECLARATION PERMIT#
I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
� ; Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOT a TRACT
W Professionals Code,and my License is in full force and effect. )
04 i L)J OYG.e- '�7
C) License# Lic.Class Exp.Date {
O JOB S11TE
d, , ADDRESS ' AFN
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IY-1- S"�'�a?✓� /,� ++�; ,r '� / n��^:i 4.1-0 1r AVi�3Z`I�F:53
Or- Date�� � :"'!' Signature of Contractor_#* `r* ,J � � OWNER CONTRACTOR/DESIGNER/ENGINEER r
r- F— o V OWNER-BUILDER-DECLARATION
W WW I hereby affirm under penalty of perjury that I am exempt from the Contractor's I r ,y�r
License Law for the following reason: FS1,.-V)AVENUE 5` l�'687 COUNTRY C":�.. B DR,4.201
Z_ ( ) I, as owner of the property, or my employees with wages as their sole LA.01.fS,,iOA CA, 92253 DOWMAD WES CSA .92201
compensation,will do the work,and the structure is not intended or offered for (760)343r7755' 1.969
sale(Sec.7044,Business&Professionals Code). USE OF PERMIT
( ) 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 TEMPORARY C;,"`7'N.YFRUC:TI Y,ta6 TI:A3a_ER AS PYR lt»UP N00461.
LO
N Date Signature of Owner
p C\I
0)
Q WORKER'S COMPENSATION DECLARATION
C) 2 z I hereby affirm under penalty of perjury one of the following declarations:
p O 1 have and will maintain a certificate of consent to self-insure for workers' VNA)A ON QSQ 14
X W �: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m < t,4111 have and will maintain workers'compensation insurance,as required by
O U Q Se tion 3700 of the Labor Code, for the performance of the work for which this
d � F— permit is issued. My workers' compensation insurance carrier & policy no. are:
Z Canter Policy No.
Cb O STATE FUND 2214-X30-Ui: r/16 X11MtiFf„t3.�M)COW,OFG'O3r ST r�'t74""�:ON �f(3S3t3.f�
J (This section need not be completed if the permit valuation is for$100.00 or less). F�!?�,��'.��1" YFX lro`U.(411MJILRY
( ) I certify that in the performance of the work for which this permit is issued, TF*MF'C."-ONOTSi.UCT104 TRA11,9.3 101-f3W-423-000 S200190
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 a•
subject to the workers'compensation provisions of Section 3700 of the Labor a
Code,Ihall.forthwith comply with those provisibnsf
Date: .I A Applicant—
Warning:
pplicant Warning: Failure to secure W,,orkers' 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 Applidation 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, SU,+`,;..°(°WAL try oWrRI,l'dTUON AND PIAN C"*WIC $200.0
any permit issued as a result of this applicaton agrees to, &shall, indemnify U.S.4 P f.,PATID"'H8 $0100
& 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
9-61
qX
work is not commenced within 180 days from date of issuance of such ITY.CALe Rt RNI FEWS MAK NOW $200,00-
d
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 I IIIIIIIIIIIIIIIIIIIIIIII
• correct. I agree to comply with all City, and State laws relating to the building 56
construction, and hereby authorizerepresentativesof this City to enter upon IE
the above-mentioned property for Inspection purposes.
RECEIPT DATE ( f BY DATE FINALED INSPECTOR
Signature (Owner/Agent)`"�<p.�i�'� l t•. '1° 7 f Date 1.f't� 3 f � !� C?I Wt
at I
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 •
BLOCKiNALL 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
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.1, _
Smoke Detectors
Temp.Use of Power
Final
Utility Notice(Perm)
0
111111110111 57
IE
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P.O. Box 1504
78-495 CALLS TAMPICO (760) 777-7000
�MOF O LA QUINTA, CALIFORNIA 92253 FAX (760) 777-7101
December 15, 2000
Ms. Kristie Porter
Country Club of the Desert
P.O. Box 1540
La Quinta, CA 92253
Subject: Minor Use Permit 2000-261 (Temporary Construction Trailer and Yard)
Dear Ms. Porter,
The Community Development Department has approved your request for a'�temporary ,
construction trailer;and yard on the north side of 53RD Avenue, east of Jefferson
_`Street, subject to the"enclosed plan and the following conditions:
1 . Obtain a building permit including an electrical permit for temporary power and
fencing.
2. Trailer shall have restroom facilities to accommodate personnel.
3. Mounted on the exterior of the trailer close to the front door shall be a written
notice providing emergency.personnel your 24-hour emergency phone number
they can call in case problems arise that need your prompt attention (i.e.,
minimum 1 " high letters).
4. Install one 2A1OBC fire extinguisher inside the trailer by the front exit door.
5. No temporary signs are approved unless separately approved by this
Department.
6. Removal of the temporary construction. trailer is required by December 15,
2001, or upon completion of the homes for this project, whichever occurs first.
An extension of time may be requested prior to expiration.
7. Trailer skirting shall be installed within 30 days if the trailer is mounted above
finished grade level.
4
8. Any permits required by the Public Works Department shall be obtained prior to
any work proceeding.
9. The temporary fencing around the construction area and trailer shall not
encroach into the 53RD Avenue.right-of-way until the street vacation has been
completed and the street closed to the public. The fencing may be chain Fink,
maximum six foot in height with no barbed or razor wire permitted. .
10. The City.may elect to add Conditions to this application request to mitigate any
problems that arise not previously addressed herein.
This decision may be appealed to the Planning Commission provided the necessary.
paperwork and filing fee of $175.00.are filed with this office within 15 days.
If you have any questions, please contact me at 760-777-7064.
Very truly yours,
JERRY HERMAN
COMMUNITY DEVELOPMENT DIRECTOR
STAN B. SAWA
Principal Planner
Attachment
c: JBuilding Y and Safety Director
Public Works Director
Code Enforcement Department
Fire Department
Sheriff's Department
PASTANVtr app mup 2000-261.wpd
kppro_ ved by: Date Reso #
❑ Planning Commission —.--
❑ City Council
"I'S Com unity Dev. Dept. C O U N.T R Y CL-UB
Initials
Case No. _Mu12 74"00-421 --
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