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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 r Exp. Date
7531W'i - 5t31d03
Date-sV'� • Signature of Contractor «� • �'% 'F
OWNER -BUILDER DECLARATION
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 of 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.
�( )i 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 S TAT SND Policy No. 1688203-0;<
(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 provisions.
Date?,' Applicant
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
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
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) 'r�'? Date
BUILDING PERMIT PERM'S
Fi l
DATE VALUATION a�w�t�pd.�.?{b' . LOT, TRACTJOB
SITE
ax u.G,.ezu BY. a
APN T %•r`r-aAti SYb l
ADDRESS
OWNER
CONTRACTOR /DESIGNER /EN6NEER
eR,V A1TJJA7F
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Et to
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USE OF PERMIT
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POOL, SPA OP. DR'lVIf:WAY AP;?fr.OAC(•i. 7 WUMt34 Tif)1H TO KA -IF CH. E K
FFR' DUE TO MU1.;T!F`11.,Z ISOVANCE OF SAME PL..A14 'PYPt
CUSTOM CONVIRM'DON "04.0 RY
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F_'.,I,AR C.I wIrl, W i.40
MECH AICALW 9196.30
P10&S'F5INOI7EF
Sib2C9NO MUT7011 Z - RESID 10"' -000-24 1 -0000 53495
.
ORADINO FEE _000 $11.0
Ella, EI ?F KIR IMPACT 12KE $7,405.00
An l;fw P"LIC %I.Aclu; - Yic ma no -E o -I m"5-Gr7:1
SUB.'�t�,.r`t<'Ai CO)RTAS.l71TJ109SIND1+c'TIXlly�('��1�},,,fi,,:y�?��
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11"
SEP 2 2 2003
CITY OP lA GUINTA
FINANCE PT. .
RECEIPT
BY
DAT FI LED
INSPE
FM
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
Drymil - Ijit. Lath
rPOOLS
I
Final
Fin I
/ -
BLOCKWALL APPROVALS
- SPAS
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 le 77— 3 _=3
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
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
Final7L41 0
Utility Notice (Perm)
COMMENTS:
--,'A
AIL
PGA TW
' FAIRWAYS ASSOCIATION
July 20, 2004
Mr. & Mrs. Herbert Kaufman
18325 West Nine Mile Road
Southfield MI 48075
RE: Pool, Spa,
80-821 Bellerive
Dear Mr. & Mrs. Kaufman:
On July 12th, 2004, the Architectural/Landscape Committee reviewed the re-
submitted plans and will give final approval upon receipt of before photos of the
rear yard.
If you have any questions, please contact me.
r
Sincerely,
Nanc C._P inson
Asst. Association Manager
CC: McIntyre Pools — Mike Polk
file
Past Office Box 1658 • La Quinta, California 92253 - Phon.e (760) 776-5100 • Fax (760) 776-51.11.