6903-092 (RER)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of periury'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 #^ 1Aq Lic. Class Exp. Date ll((��
-12� 048 14 61-1019 l •
Date r Signature of Contractorn�®
v
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 & Profe§sionals
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. issuedf%IWy,,wbr',keis''compensation insurance carrier & policy no. are:
Carrier Policy No.
(This section need not be completed if the permit valuation is for $100,00or 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 withithose provisions
yDate Applicant rf
t
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)"Date 3� " 5
BUILDING PERMIT PERM T# °°NTR°`"
9603.092 2997
DATE 3119196 VALUATION 5700 0 LOT TRACT
JOB SITE
ADDRESS 4&60 PASSE -0 T_4RAZO
IOWNER
49-6051?A., EO TA1 IVO
USE OF PERMIT
APN
CONTRACTOR/DESIGNER/ENGINEER
L'AR.RY GU711� I
78 -AOS 14NV Y 111; A 148
LA QUI orf 1 A
'eP11A.:1'El) M-1,11,Lid+" t:�'1i`�',s' RAO'C'1 ION
PI'. AN C1• W -X VI~E 112.31;
CONSTRUC.11014,17VE 101-00-418-000 $19.00
C." -fie. 953
CBLf1 2789
700.0100
(0
SULI-TOTAL CONS IRUCTION AND PLAN CHECK �3I.3s
LESS P E-PliID P,E S
4'CA1"ril.3'1i;1iMf'E FE&S JOYit DD '.�:3i 35
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 J
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Griffis
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
7424
Final
Final
POOLS - SPAS
BLOCKWALL A PROVALS -
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)
Building
Address Vr i
Mailing
Address
I4
�
P.O. BOX 1504
--{{-- 78.105 CALLE ESTADO
<-Fo /g/lA? (2LA OUINTA, CALIFORNIA 92253
zs
�L
City IZip ITel.
& Classif. I Lic. #
Arch., Engr.,
Designer
Address Tel.
City I
Zip (State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I 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.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, atter, 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 (8500).
(-; 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 Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If. however, the building
or improvement is sold within one. year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
I i I, as owner of the property, am exclusively contracting' with licensed contractors to con-
struct the project. (Sec. 7044• Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
f? I am exempt under Sec. B. & P.C. for this reason r
Dale Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that l have a certificate of consent to seif-insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
0 Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thF 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.
Date Owner
NOTICE TO APPLICANT., If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked. '
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. *(Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that 1 have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives sof this city to enter the above•
mentioned property for inspection purposes.
Signature of applicant Date
Mailing Address
City, $tate, Zip
APPUICATION ONLY
TYPE CONST. OCC. GRP.
Number
Legal Description
Project Description'ilo
Sq. Ft.
Size
No. ' No. Dw.
Stories Units
New ❑ Add ❑
Alter Repair ❑ Demolition ❑
Estimated Valuation
—8-C.2
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
r
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
7
ZONE: BY:
Minimum Setback Distances:
Front Setback rom Center Line
Rear Setback from Rear Prop. Line
Side Street Se4back from Center Line
Side Setback f:-om Property Line
FINAL DATE INSPECTOR
Issued by: Date Permit
Validated by
Validation: _ _ _
Page One
LAGUNA DE LA PAZ HOMEOWNERS ASSOCIATION
ARCHITECTURAL IMPROVEMENT APPLICATION
az
LOT# DATE 1'. 2,1
NAME(s)
STREET .ADDRESS q 6 po T , cf7 �C/
LOCAL PHONE (.��''(o
OTHER PHONE
REQUESTED IMPROVEMENT_.5�_��
PrApproval is requested for the above improvement=accorcling to the
la attached: We have attached two (�2) sets of plans outliningrk to be -donee along . Faith a complete description of the
erials to be used. Upon:. approval of this applica..tion and
rior to -commencement of the improvement, the `cert_ficate of
iability insurance will be provided,, naming the Asso=.ation as
n additional insured.
We have read the Architectural Committee Rules and/or Guidelines
31 and,have furnished copies to all contractors to be engaged by us.
We agree to comply with those Rules. We also understand that it
is our responsibility. to ensure that our Contractor(sl comply.
We acknowledge .that Building Permits for home improvements are
required by the City of La Quinta. including any modifications to
bearing walls. The cost of permits, responsibility for obtaining
them, and the subsequent inspections will be our responsibility.
In all cases, we recognize the requirement to be incompliance
with applicable building codes including, but not 1_mited to,
those adopted subsequent -to the original completion and
acceptance of our dwelling. The Association has no
responsibility. what so ever in achieving compliance N_th newer
building codes which apply as a result.. of Homeowner prompted
modifications. Further, we understand that approval wi;ll.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-b-3cks (as
applicable-).
As`- Revised .January 1 99<6
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 Agr,ee to pay the .Association an application fee of
(if required) to defer administration costs and expenses
in the Committee' -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 t e work is complete
and has been accepted by the .Homeowners Association, we may
request:arefund of .our deposit if one has been given..
Signature of a '37 n wn s:
(Signature)
(Signature)
As Revised January 1996
LAGUNA DE LA PAZ HOMEOWNERS ASSOCIATION
ARCHITECTURAL COMMITTEE CERTIFICATE
This a ion was reviewed by the Architectural Corr:rrittee
on � nd has been:
Approved Rejected Conditionally Approved with
reanired mndifinatinnG
,,.
Returned for Fur.ther'Information
Required Modifications
r
Comments
Signed:
te: R
COMPLETI= INSPECTION
Completed.work inspected acid approved:
Deposit return authorized (if applicable)*:
Comments:.,....:
Signedc Date c.
* Less. any reimbursement to the-Associationfor costsJncurred to
bring homeowner into compliance with the governing.do=uments.
rdi