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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
Of, 61M8 C-53 Wo 04311'01
Date Signature of Contractor / ,)!.
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 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.
CQ, 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 (STATE CGeMP:f NSA- 11 Policy No. 046goof dR
(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' compensationprovisions of Section 3700 of. the Labor
Code, I shall forthwith comply with those provisions.
Date: L Applicant +�A'- "�� ;r
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 conditicns 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 pursuanfto
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)��,•F�'-'✓ Date. /J
PERMIT #
BUILDING PERMIT
0110-2&2
DATE ,�, VALUATION ► b LOT YRACT
JOB SITE ADDRESS :.A5-AI.�Ar :Bjiiz Bum
'
APN -
OWNER
CONTRACTOR / DESIGNER / EN (NEER
..AdRS. k'uwal 01MLY
(WIi+'C RXIA F+001.9 & SPAS t1i"P 3Wa C01
55-M.,81g'US1wWT.M
%47^25 JON! 11A , SUNT. 0.
1-0,QXJTN A �. 922,13
PAIM �.±EN t CA. ��2d3fJ
(760)340-9000 €`plul 00355
USE OF PERMIT
4`�1•!I3101A BTRUNNQ
`
lC:IV H Ffl%»F.;4ri...f'LC9 QNi,;Y
RUM CHECK FER 101-000-439-313
CONIS1'RUC`t 1014 ?F8, 101 1R-000 �fii.S3+9
�� LY
OCT 2 5 2001
CITY OF I_A OUINTA
FINANCS 0=_PY
STT8-,f`O'1;AL CONITTIIi UC3109AND MAN CHECUe.
1.=+ D 1'F,R-PAID PEEMS
$0,00
1 91 NO W
3,�'�i
RECEIPT
*TEr' +
BY
DTE I LED
INSPECTOR
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
POOLS - SPAS
Steel
1 Set Backs
P Footings �/�
I Bond Beam /
/� Q� G/�/
�
Electric Bond
Main Drain
Approval to Cover
_
h
�!
` 6X/
Equipment Location
Underground Electric
Final
/�/�Q/p 6J�
Underground Plbg. Test
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
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
I xterior Receptacles
. F.I.
,Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
55.8sg *—AE
PGAVr.
FAIRWAYS ASSOCIATION "
July 11, 2000
Mr. and Mrs. Edwin O'Kelly
RE: Architectural Change Request
--Dear Mr. f--Mrs_.0'Kei6X: - - -=. _..._..__._........_.._...
The Architectural Committee of the PGA WEST Fairways Association has
reviewed the plans submitted for a kiva and trellis at your new PGA WEST home.
Based on its review the committee has approved the plans as submitted with the
following condition:
1. The colors to match existing surroundings.
Please contact me at (760) 564-3858 if you shouid have any questions.
Sincerely,
For the Architectural Committee
`- Ql
n J. Mon
Association Manager
P.O. BOX 13710 - PALM DESERT, CALIFORNIA 92255 - Tel. (760) 776-5100 • Fax (760) 776-5111
emaili pgawest@monazchgrp.com .
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