9807-109 (AR)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 df the Business and
Professionals Code, and my License i&in full force and effect.
License # ,.:.:' Lic.,�Class Exp. Date
542783
,Kte-*l Signature of Contractor`^ -
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:
Carrier wry q ( Y y Policy No. (�
'9.7•f�l.l'+.I°1�59Y1 I..J�4'�a(1^y�
(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' compen saticih•laws.,of California, and agree that if I should become
Subject to the workers', c6mpensatlon provisions of Section 3700 of the Labor
Code, I shall forthwith comply wlth.those provisions.
Date Applicant "�` �•-=� -�'''
Aarning: Failure to secure Workers' Compehsation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to '
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that -I ;have read this application and state that the above information is
correct. I agree:,to.comply with all City, and State laws relating to the building
construction ancl.;l ereby authorize representatives of this City to enter upon
the above-menftohed property for inspection purposes.
,S1g ture (OwnedAgent) ., Date. ? Z
BUILDING PERMIT-, PERMITN ,
l"
DATE n;� VALUATION LOT TRACT
S6.5ft 410
JOB SITE'
APN
ADDRESS 5-920 FINCvHiL1&S
OWNER
CONTRACTOR / DESIGNER / ENGINEER
55920 1>$N1~'H.M91`
48ia5 PP AiUF DR.
I...t1 t; UI NTA. C.A. 92253
PALM DESERT' CA. 92260
(70())779-0790- C RI , 4903
USE OF PERMIT
all SQJ ( GA:itiVOL OOLF CFlRT ADDITION AND WAXRRVFA VURii e(etr"
GAlLNGWCAW"' iRT 30.00 ZBF
P(:I L ANDIOX SPA 6.(W.W L3
I
�g n;�� a ^�^ q `} ` �yAt �^�p�rv� a`
n��t'.kl�C3. A l KID" 1.0.,5 if OF CO Y.S 8 xM9li.. gefl�l N
4Vvitfl�.t►P�
PL&N t1•t3-.CK. FR3 1014)00-439-319 %'1..'4A')
C-Clt f! ' I is °ro tryst t f.tli -00 .-4i 8<• M X98.0
�.
:iWO14 ! MOTION FEE', - earn 101 -ON -2413-0
QI;b\0tN01"1sl: 0
R, 0711 kICA1, F'EsE -- N1001, I01-0U4'204)0b S4.5,00
,.
-P)MMLE31W rrT1 -- }af.'nkl !OT -()!1 :lid 01111 $77,00
• P
`. V" .-kf?7 A.I., t";(')N87R,f..Tt'" n(lw AND K..A.N CHRCK
V2,57 90
9� LESS PRE-i':^UD !:}31E5
W00
RECEIPT'
DATE
B�DATE
FINALED
INSPECTOR
e
4I I
m
0
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs 2
Underground Ducts
Forms & Footings y
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck — 13
Exhaust Fans
O.K. to Wrap qj
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 -('j-
Drywall - Int. Lath
Final
Final Z
BLOCKWALL AP ROVALS
POOLS - SPAS
Steel
Set Backs -1 42al4eX zr-
Electric Bond
Footings- j2Main
Drain
Bond Beam rf -" (T ,
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test 14
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 y -
Gas Piping
Gas Test
Appliances
Final i
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)
COMMENTS:
A. P. Number:.. Address: `
Legal, Description: —Y _ City,;ST, Zip ll
.`. . w.: .p ..
ntr or Tele hone:
T'
Co acto . %/
y
-lam �
_ p _ v
Address: u i�Pl e `
Pr
Project Description:
617
City.ST, Zip: • /4. .. e Z Z G
t
Telephone:
i
7
9 .z
State Lic-.- #:: 540- 7 e3 City Lic. #
Arch.. Eng.. Designer: T::7
Address: j.�f.�f� j C44 •[e .IclOt'i
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
N0. eLUMBING FEES
ST FL,
2N0 FL.
POR
GAR
CAR P
WALL
ESTIMATED CONSTRUCTION
SO FT 5
UNITS
ROUGH PLUMB,
SO. FT. -n
YARD SPKLR SYSTEM
SO FT a MOBILEHOME SVC.
BAR SINK
SO FT .it. POWER OUTLET
ROOF DRAINS
iO FT .Z
DRAINAGE PIPING
SO FT S
DRINKING FOUNTAIN
30 cT y.
URINAL '
VALUATION S
WATER PIPING
NOTE. Not to Ca -,sea as-rocerty !ax ia!,arion
TEMP. POLE
FLOOR DRAIN
MECHANICAL FEES
GROUT
WATER SOFTENER
VENT SYSTEM :.AN EVARCOOL .,OOD
SIGN
WASHER(AUTOHDISHI
APPLIANCE DRYER
WATER SYSTEM
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
=_
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FINAL INSP.
KITCHEN SINK
ABSORPTION SYSTEM B.T U
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE. TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SO. FT. .d C
BATH TUB
SO. FT. Zo c
WATER HEATER
MAX. HEATER OUTPUT. B.T.U.
SU. FT. RESIO «i Iv. c
SEWAGE DISPOSAL
SO.FT.GAR V 4C.
HOUSE SEWER
GAS PIPING
PERMIT fEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE JPL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING A AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB,
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAq
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
t plus xf
=_
LUMBER GR,
r
FINAL INSP.
FRAMING
FINAL INSP,
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE t
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIOWSOUNO
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
ma�cv r vn a m�nw. unwrnr � ww
GARDEN WALL FINAL
.s"
TM
PGA WEST
RESIDENTIAL ASSOCIATION, INC.
PGA WEST RESIDENTIAL ASSOCIATION, INC.
Notice of Architectural Approval
This shall serve as written notification to the City of La Quinta that Mr. and Mrs. Blackwood of 55-
920 Pinehurst has gained written approval from the PGA West Residential Association, Inc.
Architectural Committee and from a Management Employee of the Homeowner Association.
Specifically, Mr. and Mrs. Blackwood has the approval to proceed with the garage addition,
landscape changes to the front entry and addition of a water feature. This signed approval must
precede the issuance of permits from the City of La Quinta.
6 -- /e),— 9'7
Date
'e'l _16 --V -
Date
P.O. Box 1060, La Quinta, California 92253, Telephone 760-771-1234 FAX 760-771-5125