CGAR (9802-119)LICENSED CONTRACTOR DECLARATION
t l; 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
r .Professionals Code, and my License is in full force and effect. -
License # Lic. Class' Exp} Date 6
vDate - Signature of Contractor
OWNER -BUILDER DECLARATION ' t f
I he 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). , • *'
( ) 1, as owner of the p(operty, am exclusively contracting;,, with licensed
contractors to, construct: the project (Sec. 7044, F 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':
O I haveand 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 ' :1 Policy No.
+v+' r's4 o+f a c,
til' :.� P i�, 'm) �..i,9�{-.a ��.
(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, tnd_agreelthat if I should pecome
VAbject to the workers' compensation p'r'ovisions�of-Section 3700 of he Labor
Code, .I-slaal qfort with comply with,those.provisions.
�Date:'.f Applicant / /iVQ =a- ` Ll ,— xi.
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
afetyfor',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 certifj 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 authorizrepresentatives of this City to enter upon
the above-mentioned property'or representatives
purposes.
vSignature (Owner/Age...,
BUILDING PERMIT PERMIT# .CONTROL#
DATE VALUATION .LOT '. TRACT
f aN
S 4 91C��i>.tBi3
ADDRESS /AZA 1� ION
JOB SITE TP
N 7451-4S1.'
t'
:t
OWNER , .'.
CONTRACTOR / DESIGNER / ENGINEER r
'• 101 KC,
hy .l.���kdw c`} ie63 i�a
.l.V
JA QUTNTA. C�t,.': .922.53 .
:I:,A QLA3%4';1 A - C.A. 9225-1
'7(+ 75 7933 (wE31'y ?'
USE OF PERMIT }
r �..
ai Jix CAR.r Crk*,", Vow4[G�f.
.E S.12.MY_A.B. YtaB,Y O.'\6.7T OF CONI41.0..f-aVC1 Ol,t
':1'1±:tRt�!18.�' .r'l�'C� �ij�iiit�,c��iit� . �, °�
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•
C>>t ttf:3i!2t� ?."ICi(� Irsr.r '901-MD-418-,Ei O SF160
r
.101-000-4204 00
.
t !'IztJNG Ivin t8SfQ ),o.t;-i -241--000CID
t.
C
LAMB
+ �
$1$121A S .
1tAC� o7twin
LESS
"1'CD"9•AL Pf1,1113NOT FCC 1lfi, x (A
;kla3
RECEIPT
DATE
BY/ _
DATE FINALED
INSPECTOR
.. ♦MSW -
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
9,Underground
Ducts
Forms & Footings
Slab Grade
�/o
Ducts
Return Air
Steel
Combustion Air
Roof Deck
_
3_�3 —
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
'
1rPoX 1A137Wz,(*7r— i
Y-0- - Qs, _
Q r
Final _ _ ���
BLOCKWALL APPROVALS
Final
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
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
Law Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
fJtility Notice (Perm)
PGA WESTII RESIDENTIAL ASSOCIATION, INC.
P.O. BOX 1282, LA QUINTA; CA 92253
(760).776-5100, FAX (760).776-5111
PGA WEST
March 3, 1998
Michael Jacobsen
5017 Lakehurst Lane
Bellevue, WA 98006
RE: 57-214 Merion, PGA WEST
Dear Mr. Jacobsen:. Y .
The Architectural Committee of the PGA WEST II Residential Association is
pleased to inform you that it has approved your request for the addition of a Golf
Cart Garage at the above referenced address. This approval is good for- a period
of six months, if work is not begun by September 3, 1998 a new application will
be required.
The Association requests that you contact its Landscape Maintenance Contractor,
Valley Gardening Service (760) 399-1844 for consultation on any irrigation work •
to be done.
Please contact me at (760) 776-5100 when work is complete to schedule a
walkthrough inspection..
Sincerely,
John J. Monahan
Association Manager
CC: Architectural Committee Board of Directors
r
Building
Address 57.2.14'
'
Owner
5unrisi compio
Mailing
Address42-60Q-.•COok' $Y.
,City - :;.,1'.- ,- Zip
Palm nigiaT 1 92
Contractor
Aaaress
P.O.BOX 1504 ' N ( Y
• 78-105 CALLE ESTADO
-.,LA QUINTA, CALIFORNIA 92253 1
BUILDING: TYPE CONST. OCC: GRP.
N,
iia 2W A.P. Number_ ;
Tel.
Legal Description "irac't 25499-1
k
" Project Description Pha si R Plan ft ~
Siam
City
Zip;
Tel.:
State Lic. *-
City
-
_
& Classif..
Lic. # ,
Sq. Ft. :2M
No.".No. Dw.
Size
Stories -, • Units,
Arch., Engr.,. �a
Designer
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑ .
Address
Tel.
City „.
Zip
State
r
f
Lic.; #
� I LIC NSED CONTRACTOR'S DECLARATION
"• I
1 herebyyrafflrm th m Ir nsed under provisions of Chapter 9 (commencing with Section
7000) of'Div�
n* t' a chess andProfessions Code,and my license is in full force and
-
Y
SGNA R ps.�.r:. y._ E
. ( /
OWNER- MILDER DECLfARATION
-
I hereby affirm rI am exem`t., m the Contr'actor's License Law for the o g
Estimated Valuation
aa��qqAA AAqq�.� l
9N
• reason: (Sec. 7039 usiness and po/essions. Code: Any city or county whic u'. s a
permit to constr Iter, improve, olish, or repair any structure, prior to. its,l •gls
-
Y LS9. -
,requires the applic for. such pe- file a signed statement that he is license t
PERMIT'AMOUNT,-'
-
S'
the provisions of .th Contractor' a Law, Chapter 9 (commencing with Se I
Division 3 o/ the Bu bss and P sons Code, or that. he is exempt therefromis
e -
-
for the alleged a tion. Any tion of. Section 7031.5 by :any applica l ' mit
Plan Chk.. Dep.
y
subjects the appl' an o a civil penal not more than five hundred dollars ($500).
/
Plan Chk. Bal.
ss
O 1, as owner o roperty, or employees with wages as their sole co qwill
do the d i' f intended -for
work, a structure t or offered sale. (Sec. 7 ess.and
Professions Cod ' Coniracto icense,
Const.
9 �p
Law does not apply to an own r` I arty who
builds or improves. ereon `an - h does • such work himself or through i mplQYees,.�•-'i.
Mech. - -73.W
• provided that's proving not intended or of/ered /or sale. 1; a bwlding
's
• or improvement old w hi ear'o/ completion, the owner -build he ,burden
Electrical
of proving that he of bw jm ve /or the purpose o/ sale.) � !
'd
- -
❑ I, as owner@f the grope` exclusively contracting with lic�yk onL orse o can.
the
Plumbing .-
- 10.
.
struct proje J(Sec..70 siness and Pro/essions Code:'Thg o'raptoi eje a Law
' does not apply fo an owner. •eerlywho builds or improves thereogr, nd`�vh ?c of cts /or,
with �
-
S.M.I.
j
- ,. - Q� •.-
�
such projects a contractor(sJ licensetl'liursuant to the Contractor's Lic n Lawy, ..
9 !� • )�
❑ I am exempt under Sec: B. R P.C. for this reason
Grading
!r rAIN
Driveway Enc.
Date Owner W17/1
Infrastructure
r.
`v
Letstmdit.
2,417r.89
4
WORKERS' COMPENSA �I LARATION
$
�� 189
I hereby affirm that f have a certificate of nt to self•insure, ora ficate of
"
- _ Worker's Compensation Insurance, or a certified/ thereof. (Sec. 3800, Labor e:)_•
- -
- -
Policy No. Company • • /
r yn
• O Copy is filed with the city ❑ Certified copy is hereby furnished.
^
;
TOTAL `14,687.73G=
{n^T.
• •� -C ERTIFICATEOFEXEMPTION FROM
' WORKERS'
REMARKS1'
ci
• •.. COMPENSATION INSURANCE t
' (This section need not:be completed if the permit is /or one hundred dollars •($100) valuation
... -. _.:
_
ti .• � �
•+e -g
f�7 :%:; �; �}, ,g.8; —04,"•,-„ ` - :.
or less.)
I certify that in the performance of thg work for which this permit is Issued, I`shall not-
Weinployany person in any manner so as to become subject to the Workers' Compensation
.tri
Laws of California.°' F
' '•..
*` ° ( f .
Date Owner' r `
sl ik
NOTICE TO APPLICANT: 11, after making this C¢[�I/(cafe ` o/ Exemption. you should become •
ZONE: - •
BY: - -
subject to the Workers' Compensation provision\oF the Labor Code, you must forthwith .
r
comply with such provisions or this permit shall be deem revoked.
Minimum Setback Distances: -
r`,'
Front Setback.from Center Line
`.
Rear.Setl akk from Rear Prop. Line `
CONSTRUCTION LENDING AGENCY % " f *
a " `'',
Side Street -Setback from Center Line i
I hereby affirm that there is a construction lending agency for the performance of the
.• s ,:
work for which this permit isrissued. (Sec. 3097, Civil Code.) �. �, •
I
r'
Side Setback'from Property Line
k Lender's Name 'r - ' s
Lender's
o >pti
j'FINAL`,DATE
•
Address
INSPECTOR
r . This is a buildin g permit when properly filled out, signed and validated, and is subject to
�• expiration if work thereunder is suspended for 180 days. - -.- •, �.
- � A,4/23/90
3 I certify that I have read this application and state that the above information is correct.
Issued by:
r=' Date~ Permit
I agree to comply with all city, and county ordinances and state laws relating to'building
construction, and hereby authorize representatives lof this city to enter the above-.
°
imentioned property for inspection purposes. '
Validated by:
Signature of applicant Date
"
Mailing Address -
Validation:
City, State, Zip
A W^y-
- ;•
1 e
`t.. '�j�r
�' f' t
F.. .s1 0. ^'t.. t •`,� �-ti :.. 1 -.r. �,.r'7� r�.'',
.S• _! - -
•a ._e{ice
�t. r:". 1.-. •.. - , -`'`„ 6`„ ,'S,��t ,l_'
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
2ND FL. SO. FT.
POR. SO. FT. ®
GAR. SO. FT. ®
CAR P. SO. FT.
WALL SO. FT. ®
SO FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WATER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
(ROUGH) J � fo
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEOUIP.
LAUNDRYTRAY
AIR HANDLING UNIT CFM
I
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET'
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER. B.T.U.
SO. FT. ®c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
REMARKS:
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
ROUND PLUMBI0517d
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
EWER ORS �116�
ROUGH WIRING
DUCT WORK
ROCK STORAGE
L OUND. REINF�30 - l'd,AS
(ROUGH) J � fo
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
RAMING —
FINAL INSP.
OFING ;_6-q
REMARKS:
VENTILATION
FIRE ZONE ROOFING:
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
11
THING f✓
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL