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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
l/
~Date / Signature of Contracto
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.
( ) 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:
Cartier Policy No.
. �'M� f`FI mt'3:1f..r2r'�:Iti`C ust�l2nPi^.rC13
(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 Sectioq 37PO of the Labor
Code, I sh II'forthwith comply with"tose rouisions.
a�Date: F � Applicants
Warning. Fallure 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)'-•• >� ZA'•4YA
PERMIT #
BUILDING PERMIT
.
DATE 1,119/9
S VALUATION Sj,%,004):()q LOT TRACTJOB
SITE
ADDRESS79-045 Cf.,LLE
APN r -
OWNER
CONTRACTOR/DESIGNER/ENGINEER
T.A. QUINTA. CG) -.j' i'.1COPszR116sS
wil'n"l C()N'�mwC' loth Co.
41 -W BOARDWALK S'178.
78120 CALLE ESMDO 92O6
PALM D SER . CA. 92211
LA Qi11N`FA CA 922153
i CI -IL# 3751
USE OF PERMIT
218 S,F. c:CY"J.%StRED CiiJ'.1'SM-F i'IRiLL r1:i:,+:DITiON
`t?.t'it,UKf10N1 15,000.00 Lu
1,
ESTMATED COST OF CONST RIWFMIN
PCIRMIT FUE SIVIVISVlF RY,
FEE MPOSI'.C' 4154 ,00
pi, AIstCiif-1,CK f11r."f; InI.f1(1!!)-Al t) -j19 6tt15:cA
C0?41S•Y•RUC'1"irJfir RIT .101.01)0-411 ,00'3 $152.00
NIEt.>HAMICAL )rlH $211.50
ta, e •e1z1C Ali. >., S2 .50
P ,a 11K!FRp,4(y F}?t; 1(11 Ffif1(1-4$,9_01 0 $22.50
`TRI111140N70'Mt;3w111-1.-('01-MY, 100.000.241.000
o 919
Dov
I l #-`iY i•�ai , �, 9' - JC�'3.C.�N ASID PI..<iytyt�iy(t;f-1FpCK
`@/►�3
�� �p / T `
I v- ���% LIESIS l;'i�.E-PA-fD.l'EEN
/c�l�S
`2$.150 Illi
•
10.i•AI♦.PERMP-T OVES DUE NO
ai96.95
V
RECEIPT
DATE
BY J
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION j
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab 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
POOLS - SPAS
BLOCKWALL APPROVALS
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 -
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
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
T4hf 0
.4
QuiRm
P.OBOX 1504
Building 78-045 Calle Ca 78-495 CALLE TAMPICO
.tea-_-- �� LA QUINTA, CALIFORNIA 92253
Owner I
La Quinta Golf Properties
Address 41865 Boardwalk Ste. 214
'ty lQuOnt�art Zi52211 776-4000
n Construction Co.
0 Call Estado Ste. 206
ch Quinta 155%253 11167-7611
State Lic.IF
& Classif. Lic. q
Arcn., tngrYau h Jorgensen
Designer g g
Address Tel.
CityI Zip I State I
Lic. N
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect.
Sir.NATURF _DATE
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
I: I, as owner of the property, or my employees with wages as their sole compensation, will
do the work, and the structure is not Intended or offered for sale. (Sec. 7044, Buisness and
Professions Code: The Contractor's License Lew does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his gwn employees.
provided that such improvements are not intended or offered for sale. If, 49wever, the building
orimprovement is sold within one year of completion, the owner -builder will have the burden
o1 proving that he did not build or Improve for the purpose or sale.)
( 1 1, as owner of the property, am exetueivgly contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Pr01®ssions Code: The Contractor's License Law
does not apply to an owner of property who builds or imprilva$ !hereon, and who contracts for
such projects with a contfactor(s) licensed pursuant to the Contractor's Li6ense Law.)
17 f am exempt under Sec. B. & P.C. for this reason
Date Owner _
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self-inaura, gr a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Wpor Qode.)
Policy No. Company
n Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dgll.?rs ($100) valuation
or less.)
I certify that in the performance of thV work for which thip permit is issued, I shall not
employ any person in any mannersoas to become subject to the Workers' Compensation
l
APPLICATION ONLY
BUILDING: TYPE'CONST. OCC. GRP.
A.P. Number 769103007-3
gal Description
eject Description Covered outside grill
addition
Sq. Ft. a,S No. No. Dw.
Size Stories Units
New ❑ AddlHZ Alter ❑ Repair ❑ Demolition ❑
US
T LI(zetiy V1 L uA-TION
Date_
NOTICE TO APPLICANT. wner It, after making this Certificate of Exemption - you should become
ZONE: BY:
itimated Valuation
•� ,� „� ��
1
PERMIT
AMOUNT
Plan Chk. Dep.
Rear Setback from Rear Prop. Line
Plan Chk. BiL
•
Const.
Side Setback from Property Line
Mech.
�( .
Electrical
FINAI; DATE INSPECTOR
Plumbing
22 , 5D
S.M.I.
•
Grading
`� ``'�i ,
Driveway Enc.
�^_ ! /
Infrastructure
`ValIdeted by: -• i R 5
Signature of atlplicant Date
_)�'� / i�S
"0
Mailing Address
alldatlon: r. \
TOTAL
REMARKS
Laws of California.
V
Date_
NOTICE TO APPLICANT. wner It, after making this Certificate of Exemption - you should become
ZONE: BY:
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
Minimum Setback distances:
comply with such provisions or this permit shall be deemed revoked.
t +
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY
Side Street Setback from Center Line
I hereby affirm that there is a construction tending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Side Setback from Property Line
Lender's Name
Lender's Address
FINAI; DATE INSPECTOR
This is a building permit when properly filled out, signed and validated, and I§ subject to
it thereunder is for 180 days.f�
t1�"y'
expiration work suspended
I certify that I have read this application and state that the above information is correct.
qllsl;�`d�by: n Date Permit
I agree to comply with all city and county ordinances and state laws relating to building
`� ``'�i ,
construction, and hereby authorize representatives -of this city to enter the above.
�^_ ! /
mentioned property for inspection purposes.
`ValIdeted by: -• i R 5
Signature of atlplicant Date
_)�'� / i�S
"0
Mailing Address
alldatlon: r. \
City,
City, State, ZipI ^f '.4
WHITE = FINANCE YELLOW APPLICANT PINK = BUILDING DIVISION
I
SUPPLEMENTAL REPORT TO SAN.
SUBJECT go
ADDRESS''
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
ENVIRONMENTAL HEALTH SERVICES
FORM # DATE
PERMIT NO.
REMARKS:
INSPECTOR'
A(i
r0 ,moo.ci
ap,
V
A h
DEH -SAN -118 (Rev 2/96)
Distribution: WHITE -Office; CANARY—Owner; PINK—Office