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9511-152 (RER)
LICENSED CONTRACTOR DECLARATION I hereby affirm 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. 424048 B 12/31/95 License # Lic. Class Exp. Date Date t� Signature ofContractor k./�7�/6/) ..,,.� OWNER -BUILDER DECLARATIbN I hereby affirm 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: Carrier ern Policy No. 1-1/4 (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 shall forthwith comply with tho a provisions. Date:' Applicant __ .n 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/Agent),.. , 11),0 jP j„ Date f el ALCM BUILDING PERMIT PERMIT. ii517 l:�2 DATE 11/301!)!5 VALUATION S4N.ft LOT TRACT JOB SITE ADDRESS PASCO TA RA O 748.613 646.082-007 OWNER CONTRACTOR LARRY GUIVITZ MORRIS 13 & EVELYN SI' PHENS 7,13651- WY 111, #148 49613 PASEO TAR.AZO LA QUINT.A CA 92253 LA QUINTA CA 92253 (619)564-6927 CBL# 2789 (619)771-1761 DESIGNER/ENGINEER USEOFPERN jFNERALWILDING' FEE DESCRIPTION FEES CONTRACT AMOUNT 100.00 ,LS F�',STiMATED COST OF CONSTRUCTION 400.00 PURAIRT FEE SU RMMAIRY C"ONSTR.UC'TION rM 101-000-41844 530.00 SUB-T©'l'AL CONS) RUCTION AND kAN CHECK Lrss PRE -PAID FEES $30.00 $0.00 u ~, RJOTALPERMI.TFEES.DUENOW$30.00 � � �f�fp� 995 Qy RECEIPT DATE BY DATE RNALED 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 AP640VALS POOLS - SPAS 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 Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Vottage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: v Laguna De La Paz P.O. Box 799 d Rancho Mirage, CA 92270 (619) 564=8864. FAX (619) 564-8867 ARCHITECTURAL VARIANCE REQUEST UNIT # DATE 75 , NAME. STREET ADDRESS LOCAL PHONE #—.7 7/.—/ 76 OTHER PHONE ' To The Architectural Committee: We, .the undersigned•owners,.request your approval of the modifications.proposed.on.the reverse side of this.form. Attached are drawings of the work to be done; types- of material to be used are indicated on the drawings. We understand that building permits for home improvements are 1.required by the,City of. La Quinta and that the-cost.of the permits and responsibility, of obtaining permits and subsequent inspections will,be borne by us.. -We acknowledge that all approved changes in the original design will be at our expense; that any damage to or relocat_on of. .existing sprinkler systems, underground utilities,-bu_lding structure and exterior landscaping -or other damage resulting from construction of these permitted improvements will be at our expense; and that maintenance'of the permitted improvements will beat our expense. „ SIGNATURE OF ALL ' OWNERS: ) �C�C ��✓t�K1 J