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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
6A.;61428 C53 .MC CA X7,31A X
Date /�1 � ? `? Signature of Contractor % �'• N �,! s ,
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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.
( 9 1 have and will maintain workers' compensation insurance, as required by
STc_t1gn'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 ,STATE C:ti MPLINi3;h?l Policy No. 04&6168-?"li 113
(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 pro,Y;isions.
Date: ? - d.1' Applicant f
f, AV
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 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
4correct. 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
the above-mentioned property for inspection purposes. ...
Signature (Owner/Agent) i yA/ �'%• Date /�'"-A
SUILDING PERMIT PERMIT#
DATE VALUATI(5N,��.qq ryry LOT TRACT
ZA
JOB SITE
APN
ADDRESS W -d D AUTTISROL
OWNER
CONTRACTOR/DESIGNER/EN (NEER
UKaT0VK1'rNfE:�i_,�0R7 C:L�C��sUNT�"�.� .WC.
t:tbt,: ,-X)P�l.F�11C)t0i: r%93at U:fr: TT CC
200 L ANIX 01001
86-100 fiJfJ atTI.. E 544
ESC"C3NZ'sMO C.A. 92 Q23
CC)AJ_4h-FF�1:.1t 4 C -UN. 92236
(760)398.,9222 CIB -,1 00355
USE OF PERMIT
-PO 01, AMJ-Va.R SFIA
.NOialJ" PA, 58Q(AW3I
PLACT AT tPR&P3 AL , R iNUPF?CT},ON, EQUIPMEWT ENCix}t URF `� `i"
11+ICi,i�:OL33
POOL ,1 IKID/011 SPA U,
UL -t; 2UO3
ITY OF LA CIUWTA
FINANCE DEPT.
3-9-J' KAilED 009.1`'O COMYRIUMON
1811XV.00
.L;`A?..LiA'YiFt��, J35.I!.•i. f;ttJ UFS. J.7(U'S•..•�:Y.
PLAN CHECK FILM 101.000.439z-31 8 $122.83
Cf?NSMUC TION FEE 1011-000-4418-000 ``x`189.00
MECHANICAL FEL --POOL 1-01-000-4Z1-000 6231.00
BLECTRICA.1, Ff,% 6- P001- 101_000 I2 0_000. $45.0
P:L7.1N111I N 0 F fZ1•- P00L, 1€11.000-419.000 $27.01
SUB IOT'AX CSC?1`tXI:N.T G'`I.XYF,.1V,)yT) P��yy�..A��{fyy��C��"jjri��jj
qy�}'�� (��vV
1. V53 l".%i.Cif":i AM VES
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F '4�1b-'•LI+l
RECEIPT
DATE '�
BY-
DATE�I�t�D
INSPECjA134
RF
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
BLOCKWALL APPROVALS
steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Fina
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
9
est
Applianc*s
Final
Xf Z /
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)
COMMENTS:
FAIRWAYS ASSOCIATION
August 11, 2005
Dr. & Mrs. Roil Kvitn.c
151.5 L. California Blvd.
.N.5.tdcna CA 91.106
Re: 56-070 Baltusrol A.rclutectural./l:,an.dsca.l?e Applications
Landscape, Pool, Spa, peck, 13T3Q and .Fire place
Dear Dt. & Mr,,. Kvit:ne:
At the July 18"', 2005, Architcctu.ral/La.tt.dscape Cotntnittce. meeting the Cotz,mittcc reviewed
the subtnitted' plans for the .landscaping, pool, spa, deck, BBQ, and fire place and has liven
their approval with the .following conditions:
+ The .fire p.l.lce is limited to a height of 6' and must be 5' .f..totn. the side walls.
+ J'hc citrus trees must be 5' .from the property lines. (Dwarf varieties are suggested)
'T'he C;ali.fortua Pepper tree must be 1.0' from the property lines.
+ Drains trust be installed fl.owi.ng to the street: and cored through the curb_
Tf you should have an.y questions please do not hesitate to contact Inc at any 6.mc.
Sincerely, ,
Nancy C.. Parkinso. , CCANI, (,MCA
Operations . .anager.
For the Architectural/L.andsca.pc Com.mittcc
Cc: Steven l:.,ogolu.5o Fax: 818-760-4672
Post Ofhcc Box. 1690 • La Qu.inta, Cal.i.fo.rttia 92247• Phone (760) 776-5100 • fax (760) 776-511.1
O`���� CITY OF LA QUINTA'SUB-CONTRACTOR LIST _
JOB ADDRESS PERMIT NUMBER OWNER.
' BUILDER
This form form shall be posted on the eob with the Building Inspection Card at all times in a conspicuous place. Only persons appearing on this list or their employees are authorized to work
on this job. Any changes to this list must be approved by the Building Division prior to commencement of work. Failure to comply will result in a stoppage of work and/or the voidance
of building permit. For each applicable trade, all information requested below must be completed by applicant. "On File" is not an acceptable response.
Trade / Classification
Contractor
::::.:.:...:::. State:.Contractor .s. License.... ;... Workers.Com egsatibri1risurance:
City. F3iis ries
Company Name
Classification
(e.g. A, B, C-8)
License Number
(xxxxxx)
Exp. Date Carrier Name
(xx/xx/xx) (e.g. State Fund, CalComp)
Policy Number
(Format Varies)
Exp. Date
(xx/xx/xx)
License Number
(xxxx)
Exp. Date
(xx/xx/xx)
EARTHWORK (C712).
CONCRETE (C-8) :.
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042�Z
21/4
STRUCT..STEEL (C-51)
MASONRY 1C-29)
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PLUMBING (C-361
-A-?7 i
LATH; PLASTER (C 35)
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646
6( ((fib
b 9' 2-9-z-
L(64
DRYWALL (C-9) ..::..:
HVAC.
ELECTRICAL. (C.,10)1:-,..` .
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C . Sj�
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0+1 3 GZ
4(0E
ROOFING' (0-39).:;
SHEET. METAL (0-431
FLOOkRING
GLAZING (C,'17):... -
C -17).
_7
INSULATION`.(C-2)
SEWAGE DISP.. (C-42) .
PAINTING (C=33)
CERAMIC TILE (C-54)
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CABINETS (C-6)
FENCING (CA 3)
LANDSCAPING (C=27) .:
POOL (C-53)
TELEPHONE (760) 777-7012 FAX (760) 777-7011
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner/Budder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an employer and you are subject
to several obligations include State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Administration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contracts are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
La Quinta, CA 92253
(760) 777-7012
FAX: gAq 777-7011
f r S:
lc:6� U
O ER'S SIGNATURE/DATE
PROPERTY ADDRESS
�S 41(& 17
PERMIT NUMBER(S)
Bin # e
•�1� , ''��` ( City of LQ QUinLA
11 Building 8t Safety Division _
—P.0. 8ox-1SO4, 78-49S-Ca Ile Tampico
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit t!f -- �—� _
Project Address:th
Owner's Name: X � OQ 1� 1 v �-�.
A. P. Number:
Address: y �5�� '�, IVA
Legal Description: �d�?�L
City. ST, Zip: Y,or b
Contractor. )(
Telephone:
Address:
Project Description:
City. ST, Zip: Y
t13
Telephone: one: x
2
State Lic. # : X, I City Lic. #:
Arch., Engr.. Designer:
-51 A
Address:
City, ST, Zip:
Telephone:
an c
Occupancy-
Construction TY P e: cu
State Lic. #
State
it Demomo
Project le one): NewAdd'n Alter Repaira
Name of Contact Person:v
Sq. Ft.:
# Stories:
# Units:
Telephone # of Contact Person: IC
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING PERMIT FEES
Plan Sets
Plan Check submitted
item Amount
Structural Calcs.
Reviewed. ready -for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
Title 24 Calcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2a' Review, ready for correctionissue
(� Electrical
Subcontactor List
Called Contact Person
�� Plumbing
Grant Deed
Plans picked up
S.f•1,1.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
''' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date.of permit issue
School Fees
0U� 1/r
G sem.
i
Total Permit Fees