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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
Date , : ig Signature of Cor factor4a
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.
id
( ) I have and will maintain workers' compensation insurance, as required by
Son 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 MAT I0NA1, U141.ONp Policy No. 7035,300
(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 s all forthwith comply,with,those provisioW
APpli aQt _ .k�t oN, 1v
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 authorizejrepresentafives of this City to enter upon
the,above-mentioned property for ispection purposes.
Signature (OW er/Age,t) ; - A"')Date i
BUILDING PERMIT PERMIT#
`K,
DATE0 *, VALUATION $2 M LOT 120 TRACT
JOB SITE�riX y
ADDRESS ®��QS,�'l Q�iZleUi7ldiAt�i
APN
OWNER
CONTRACTOR/DESIGNER/ENGINEER
91.260 AVENUE 62.
81.260 AV ME 152
'11=11 - Cad 92683
'lMMMAL CA €2881
USE OF PERMIT
9 LAY' dl 61 0ARIXT,14 "oV7Ad.1., C RCO STA14DARD .
At
6 Ft IVAbb ?3A LF
1SY.COST OF CO`1R1JMON
FERJJFUSRqWA-p
CONSTRUCTION FER 101-000418-000 S0,00
=13-7,Y_eUL x.'01=.')C''T1014 AND PI.,A , Ck1WX
$45.00
LESS
20106
MAR 14 2PUB 03
CITY OF U", `4k1,rl a1A
Ff@.f�NCr2. DI=F
RECEIP
DATEBY
Te FlP LE
IN OR
.-:
Gr ...,_
._ IV' /V
INSPECTION RECORD
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
O.K. to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drvwall - Int. Lath
OPERATION DATE I INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Gas Test
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
FinaUtility Notice
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings /
Bond Beam s! 3 '
Main Drain ,
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
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
I Pool Cover
Gas Test
COMMENTS:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underaround Conduit
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
FinaUtility Notice
07/29/2003 TUE 16;13 FAI 760 777 6119 Trilogy at La Quinta
1002/002
Trilogy atLa- Quinta. Maintenance .Association
July 28, 2003
ALFRED W. & BARBARA M. GIESE
81675 B1Z1 MEBUSH LANE
LA.QUINTA, CA 92253
Prnpgty Address; 81675 BRMLEDUSH LANE
Dear MIL & MRS. GIESE:
We are pleased to infomi your that YOM plans for installation of lambea e, ape, pad & spa with rock
wuff atl, barbecue, lvw vottage figbtaw and E¢co= have been app raved by the AmMachmW Connnittee per
your drawmgswft the Mowing eoadidon(a):
t. The gmrt d veneer Sobb most mw all aides of the Rmplece.
2. The bait ecwe m.=t* pni9d back from the end of the d' pzlva curls.
3. Tat Tiwrt� Mesquft trees am not on the approved int of 6m sad most be substituted for trees
dwt are on the approval lid _
— nis ap"v�1_<�ves.c�tY rat ro.e� +sem!+• ►,r�►_ __per. yx�•f. .. fo; ,�r.�.: r� �;, ::r w .:. h, tr:s s; (jr-
build
,. build an any pwpmty other than that o£ the applicam This sppmW is Delated sokly to the items nemVed for
app mvel by the CC,R's in aeooe+dsnoe with the A dAbclluat Gu'tde&km The approved does trot extend to the
qualify of wo& done by you' arditect, or omoactos, or to aW sLntmAu81 aWnea4, w1b aWbominrg, or site
grading and HBe • You rue urged to obtain the. oftTim of a stm beret pmfessiwW for
coomftlon as rumdod. '
Pk:aso be advised flat ft •appau val does not relieve you ft m obtambrg wW neces=y buildmg penm fran
the gov=wu tidal agencies involved. Thu& you for your pdknoe in this matter and for cmnptyhV with the
Association's policies and sumdands.
Sinoet+ely.
For the Archin cUnW Committee
Kirit Watilo, CCAM
Assouidion Manager
Eacbsures
cc: Board ofD vmors
AarchroerUzn1 C n niiftc
M6*e d by Flet gw ftop r y M~Htew. Im.
60-311 MIOD Parkway, L4 Nlnf4 CA 92253
76017776051 800.40&2284 760/77761 iP f x
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