602-074 (RER)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with
10
r Lu . Section 7000) of Division 3 of the Business and Professionals Code, and my
CD License is in full force and effect. 11 i6 )il (4 i 11V3 U9,5
r- W LiCggi4se # Lic. Class Exp. Date
Z0 to Signatureof Contractor
c'o 0 0 OWNER -BUILDER DECLARATION
J W I hereby affirm that I am exempt from the Contractor's License Law for the
LL following reason:
U) ( ) I, as owner of the property, or my employees with wages as their sole
Z 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, aril exCIUSIV91y coneaCtng with licensed
contractors to construct the project (Sec. 7044, Business & Professionals Code):
( ) I am exempt under Section B&P.C. for this reason
LO Signature of Owner
N
OU rn WORKER'S COMPENSATION DECLARATION
CL Q I hereby affirm under penalty of perjury one of the following declarations:
Z ( ) I have and will maintain a certificate of consent to self -insure for workers'
Lo �< O compensation, as provided for by Section 3700 of the Labor Code, for the
X w LL performance of the work for which this permit is issued.
p J J () I have and will maintain workers' compensation insurance, as required by
m Q U Section 3700 of the Labor Code, for the performance of the work for which this
d tJ permit is issued. My workers' compensation insurance carrier & policy no. are:
d rn H Carrier td1A. Policy No. VA
qT Z (This section need not be completed if the permit valuation is for $100.00 or less).
r- a() I certify that in the performance of the work for which this permit is issued,
C7 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.
pote: 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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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/Agen�,/ Date
ALC "BUILDING
PERMIT 1
PERMITSl6U�s
DATE "�fv ty
VALUATION �"yY r•xr�r LOT
TRACT '
JOB SITE ADDRESS >l�rr1�t,if�.fJ!
APN
OWNER
CONTRACTOR
f, , ARRY G 11, ]k f 17
C HAW, !, 81. C;LDA NT: IRS fAL't
i LIWY t 11, #148
49W-5 RASE0TjkRjka)
1,,.A QUINTA CIX Q2531
LA Q1,I1N-VA C.'A. 92VS3
(619)56 V4,0927 1 '}(N
DESIGNERIENGINEER
IIRFnFPFRlAITtt;1'+E,1�IiLr �.�-•1�t1,�#�p.
iWlf ALL <Q" x 49" QLASS 13Lfx:K W.W1,0W k1k3'rHK HAITI
FEE DESCRIPTION
FEES
VikL>:iAT1O>`r tx,.90
]E;S'3'M& TED MST OF CONST RUMIGN
400.04)
i1'K:K11'!# 11' F EC 8ILBIVFMAKY
C0NTVR1.1C'C10i,I.N F.',E 1101-000-44114-000
SUB3TO" .A.LCONS'1'[tC3CiION.�.ND.PLAN C,�iECEd
S15.00
LESS PRE-VAIO FEES
$0,00
'a`i?TAL PERMIT FE RS OVE NOW
RECEIPT
DATE
BY
DATE FINALED
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 Wali Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL AP ROVALS
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)
Page One,
LAGUNA DE LA PAZ HOMEOWNERS ASSOCIATION
ARCHITECTURAL IMPROVEMENT APPLICATION
LOT## DATE
,NAME(s)
STREET ADDRESS 49 (60' PA 5ey) I .Q- Pa -2- )
LOCAL PHONE �� 9� 5-6�-366 OTHER PHONE
REQ[IESTED IMPROVEMENT cLfYS�i�G%i
Approval is requested for the -above improvement >accor-di.ng to the
plans attached. We have attached two (2) sets of plans outlining
the work to be done along xi.th a complete descript_on of the
materials to be used. Upon1-approval of this application and
'prib to commencement .of the improvement, the 'cert.i_"ca a of
4if it'ty insurance will be rovided, namin�__Assocatron—as-
_ a insured.
We have read the Architectural Committee Rules and/or Guidelines
and have furnished copies to all contractors to be enga,ced by us.
We agree to comply with those Rules. We also understand that it
is our responsibility, to ensure that our Contractor(s.) comply.
We acknowledge that Building Permits for home improvements are
required by the City of .La Quinta including any modifications to
�3+ bearing walls. The cost of permits,responsibility for obtaining
them, and:'the subsequent inspections will be our respor_-sibility.
In all cases, we recognize the requirement to be in compliance
with' -applicable building codes including, but not limited to,
i those adopted subsequent - to the original completion and
acceptance of our dwelling. The Association has no
responsibility .what so ever' -in achieving compliance -with newer
building codes which apply as a result.. of Homeowner` prompted
modifications. Further, we understand that .approval will not be
granted. for any modifications which directly or indirectly
conflicts with the Declarations of Covenants, Conditions, and
Restrictions. We also understand we are responsible for the
accurate determination of property lines and set -backs (as
applicable).
As -.,Revised January 1;996
Page Two
We also understand that we will be responsible for all costs of
this improvement and for costs associated with any repair to the
common area occurring as a result of implementing this
improvement. Examples include, but are not limited to, sprinkler
and irrigation systems, utilities, buildings, lawns, plants, and
drainage. Further we recognize that any modifications to the
common area irrigation and landscaping scheme are subject to
formal acceptance by the Association. Any required remedy to
achieve the required maintenance standard or irrigation standard
is our responsibility. Additionally, we understand that the job
site must be left reasonably clean at the end of each day and ,
that no debris nor dirt may be dumped on the project. We
acknowledge that walls that have to be removed or partially
removed. to permit digging equipment access must have prior
permission and must be replaced the same as wall removed Any
maintenance -or replacement of permitted improvements, except for
certain landscaping, which are beyond ".initial" improvements
shall be the homeowner's responsibility.
..We agree to pay the Association an application fee of
$ (if required) to defer administration costs and expenses
in.the Commi.-ttee'.s.review..of the plans and specifications
We further agree that this improvement will be completed in a
reasonable and diligent manner .(but no longer than six (6)
-months). We further agree that ..1) if we do not 'correct any
damage caused as a result of implementation of this improvement
or, 2) if we fail to complete this improvement within the allowed
time frame, the Homeowners Association may elect to complete the
work and/or repair, and we will be responsible for the actual
costs of such work. We.authorize the use of our deposit, if any,
held by the Homeowners Association to be used as partial payment
for this purpose. We understand that when the work is complete
and has been accepted by the Homeowners Association, we may
request:akrefund of .our deposit if one has been given.
Signa ur oLy 1 ners:
(Signature,
(Signature)
As Revised January 1996
F
tt ir ,
aM
LAGUNA DE LA PAZ.HOMEOWNERS ASSOCIATION
ARCHITECTURAL`COMMITTEE CERTIFICATE
ThiV /Mion was reviewed by the Architectural Committee
on nd has been:
Approved Rejected Conditionally Approved with
required modifications
set forth below,
Returned for Further Information
Required Modifications
Comments __G1
Signed
COMPLETION INSPECTION
Completed work inspected and approved:.
Deposit return authorized (if applicable)*:
Comments: °
Signed:.,Date:—,.
* Less any reimbursement to the Association for costs incurred to
bring homeowner into compliance with the governing documents.
As. Revised January 19.96