0101-183 (MISC) LICENSED CONTRACTOR DECLARATION PERMIT#
i-U., ., 'I I hereby affirm under penalty of perjury that I am licensed under provisions of BUILDING PERMIT
.I— Chapter 9 (commencing with Section 7000)of Division 3 of the Business and DATE VALUATION LOTTRACT
04 W Professionals Code,and my License is in full force and effect. O •f!3'•lg3
O =) ch License# Lic.Class Exp.DateCY
JOB SITE APN
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c6o ZO Date a { � 1 Signature of Contractor
OWNER CONTRACTOR/DESIGNER/EN WEER
J C) OWNER-BUILDER DECLARATION �C)C��'�RY CLUB PJA ITNE Z8 T�A,14s 40 C.APT °i'ld.M0 J--%TrVK0.1 WT
W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's '83.100 ANTEMM1,53 79687 COUNTRY CLUB DRV2i<1
� a
License Law for the following reason: a ,
N :t:..E''.��T�I1!��'r� CA 92253 BERMUDA:Ov'R1Ti,.S CA 92201Z ( ) 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 �0}3� � � a�'FaSt
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 ;�i;�'1;yP�47�,�,,);,6�1;$� AJ i.
Code). 111111111111111111111111169
N () I am exempt under Section B&P.C.for this reason 231'M.1'Of:sUs CONSTRUCTION')hZ:A1L4IS laTSEt.;Vlfl '2000460IE
O N Date Signature of Owner
CID
Z WORKER'S COMPENSATION DECLARATION
ip Q tr I hereby affirm under penalty of perjury one of the following declarations:
r FZ O O 1 have and will maintain a certificate of consent to self-insure for workers'
X W �L- compensation, as provided for by Section 3700 of the Labor Code, for the
m � Q performance of the work for which this permit is issued.
Q U (�r)1 I have and will maintain workers'compensation insurance,as required by
(j C) Q Section 3700 of the Labor Code, for the performance of the work for which this
0- rn permit is issued. My workers' compensation insurance carrier & policy no. are:
`t Z Carrier Policy No.
000 O fJT.a.IZ IFLr D ��5+-�ilp��'�1� VbIrm 'iM)C051):'QST`!'�C•�)a+Ttir'3:1TU�'.L�'ON :eyllt3D.Uf)
Q (This section need not be completed if the permit valuation is for$100.00 or less). RR NUTn' LWr
J ( ) I certify that in the performance of the work for which this permit is issued, _FfAp CI4:11' i TR,S:TION TrUllIS)10 1_000.4.714_000 $200M
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'compensationfprovlsions of Section 3700 of the Labor
Code,I shall forthwith comply with`t.'ose provisions.
Date: 7, Applicant r 4 ffiJ
e. � 'P
Warning: Failure to secure Workers Compensation coverage is unlawful and
shall subject an employe'rto'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 pursuant4b OUR-Tc"ti,.'t:f , AND p'.(;."r`H3:£,`l�. $200.00
any permit issued as a result of this applicaton agrees to, &shall, indemnify L ..9:3 Pkg-nmo3*k.: $0,00
& hold harmless the City of La Quinta, its officers, agents and employees.
2.Any permit issued as a result of this application becomes null and void if n ,�, A 10- T i O,, UE OW �0.
work is not commenced within 180 days from date of issuance of such oO1 eta�...�e >ti:_ � �$ "3 .a1� � )•4
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 JP►N �®�
• correct. I agree to comply with all City, and State laws relating to the built ng
construction, and hereby authorize representatives of this City to enter upon Jae ,
the above-mentioned property fo'rrnspection,purposes. t,
9)/ t ��; RECEIPT DATE ' f BY DATE FINALED INSPECTOR
,Signature (Owner/Agent) �'r3f �f/ 'f4/� �tn Date 's
I �
+ I
INSPECTION RECORD
`a r
OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR
BUILDING APPROVALS MECHANICAL APPROVALS
Set Backs Underground Ducts,
Forms&Footings Ducts
Slab Grade Return Air
Steel 3 Combustion Air
Roof Deck Exhaust Fans
O.K.to Wrap F.A.U. ;
Framing Compressor I
Insulation Vents I
Fireplace P.L. Grills r
Fireplace T.O. Fans&Controls I
Party Wall Insulation Condensate Lines
Party Wall Firewall
Exterior Lath I
Drywall-Int.Lath i
. I
Final
Final POOLS - SPAS '
BLOCKWALL APPROVALS steel
Set Backs Electric Bond
Footings Main Drain I ;
Bond Beam Approval to Cover i
Equipment Location'
Underground Electric --
Underground Plbg.Test
Final Gas Piping I
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 r
Final j
COMMENTS:
Final
Utility Notice(Gas)
ELECTRICAL APPROVALS
Temp.Power Pole
Underground-Conduit
Rough Wiring
Low Voltage Wiring I
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. I
Smoke Detectors I
I
Temp.Use of Power
t
Final
Utility Notice(Perm)
� •���a lra^ I 1u� �„;;,�Q t � ham.
` P.O. Box 1504
78-495 CALLE TAMPICO
(760) 777-7000
LA QUINTA, CALIFORNIA 92253 (TDD) (760) 777-1227
December 15, 2000
Ms. Kristie Porter
Country Club of the Desert
P.O. Box 1540
La Quinta, CA 92253
Subject: Minor Use Permit 2000-260.(Temporary Trailer)
Dear Ms. Porter,
S
The Community Development Department has approved your request for a temporary
trailer 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.
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 trailer is required by December 15, 2001 , unless an
extension of time.prior to expiration is requested.
7. Any permits required by the Public Works Department shall be obtained prior to
any work proceeding.
p:\stan\Itr app mup 2000-260.wpd ��
8; 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:; Building and Safety Director
Public Works Director
Code Enforcement Department
Fire Department
Sheriff's Department
P:\STAN\Itr app mup 2000-260.wpd