9512-062 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm that I an cert under provisions of Chapter 9 (commencing with
Section 7000) of Division 3%f the Business and Professionals Code, and my
License is in full force and effect. 5561SA :?
236 C!?.8197
License # Lid.- lass 'Exp. Date
Date Signatureof Contractor
. OWNER -BUILDER DECLARATION
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 Signatureof 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 c,,•. - T t Policy No. I�19�r�a
(This section nee 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 those provisions.
Date: Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and shall
subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3708
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his application.
1.- Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under -or pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, its officers, agents and employees.t•
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180'days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon the
above-mentioned property for inspection purposes.
Signature (Owner/Agent) Date—
ALC 0
ate
A`°"
BUILDING
PERMIT
PERMIT*
DATE 121.2/95
VALUATION S.1 5.,400,0C
LOT
TRACT
JOB SITE ADDRESS
APN
79-845 NOL.4N CIRCLE_
OWNER _
CONTRACTOR
SUNP SE POOLIS
DIANNE CSiANBACHER.
44028.ELK140KNTR.
SAME
PALM DES,IMT CA 92260
LA QUINTA CA 9225.3
(614)340.5521 CBL# .I.V4
DESIGNERIENGINEER -
USE OF PERMIPOOL .ANDIOR SPA
POOL ANIS SPA
FEE DESCRIPTION
FEES
CONTRACT AMOUNT 15,400.00 LS
ESTIMATED COST OF CONSTRUCTION
i x,40(1.130
PER -MIT FEE S[711+ MANY
PLAID CHECK FEE 1.0.1-(100-439-318 51 I L O
CONSTRUCTION FEE 10.1.00GA1$-000 5171.00
MECHANICAL I M31-- POOL 101-000421-000 s24.0�
13LEC-11?ICAL ;FF$ -- POOL 101-000-420-000 545:00 `
PLUMBING FEE — -POOL 101-000-419-000 $27.00
SUl3-i'O f.Ala CONSTRUCnON AND PLAN CHECK
$3:18.15
•• LESS PRE-PJVD.FEES
$0.00 '
TOTAL PERMIT FEES DUE'NOW
S378.15
56
.
RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings i
Ducts
Slab Grade
Return Air
Stnel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Frs-yning
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 APPROVALS
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 Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles [ _
G. F.I. '
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) f.
COMMENTS:
I . . MEMORANDUM
�+ CASE: q5- V-9 Location (a) 6L-o6sciVIT�
Request(s) : cn7--- of ,e
Your setback adjustment application is hereby approved, subject to,
the following conditions:
Conditions:
1. Obtain a building permit from the Building and Safety
Department.
2. The.other Zoning Code provisions shall be met.
3. If ground excavation is required, please contact Underground.
Service Alert (USA) at.1-800-422-4133. The. service is free of
charge provided USA is given at least two working day's'
notice.
4. Additional Conditions:
After review it was determined that:
1.. This adjustment is consistent with the intent and purpose of
the Zoning Ordinance.
2. There are special circumstances applicable to the property,
including such factors as size, shape, topography, location or
surroundings that justify approval of .the adjustment. These
circumstances are:
Thank you fG;F your cooperation.
-Sin ely,'
o it evelopme
Attachments .
c: Building and Safety.Department
{
CASE NO: 3C
CITY OF LA QUINTA FEE: $100.00.
PLANNING & DEVELOPMENT DEPARTMENT
APPLICATION FOR SETBACK -ADJUSTMENT
r,
APPLICANT: Submit this. form with two copies of a scaled site plan,
drawn to adequately depict the nature of the request. A nonrefundable
fee of $100 is required when'the Application is submitted. Check must be
make payable to the "City of La Quinta".
If the Applicant is not the owner of 'tie- property, a letter must be
submitted by the owner .authorizing, the Applicant to execute this document
in his behalf.
PLEASE) PRINT. OR TYPE
APPLICANT/CONTRACTOR: ���;1Z1)1_ l ��L.S DATE
CONTACT PERSON ( IF DIFFERENT) t'��t.ul T}�1C�'I PHONE'
MAILING. ADDRESS : -7 3
(Address) (City) (State) (Zip)
OWNER'S NAME: _ `} = PHONE
MAILING ADDRESS: _x lZ')
(Address) c, (City) (State) (Zip).
STREET ADDRESS OF PROPERTY: b y Iiiy I �k} �� Wd QJ, IkAA 1
LEGAL DESCRIPTION OF PROPERTY:
ASSESSOR'S PARCEL NUMBER:
ADJUSTMENT REQUESTED:
LOT # TRACT
REASON FOR REQUEST: 104vtip)'u PzL D\mIC
��✓�4\moi ►�t`�\�A
S
�• * * * * * � * *' � J{ * * * * * * A J{ � !{ Ii � * J{ * J{ A A A A Ia * A * * !i * � * * * * * * * * * A J. J. Ji J{ !{ * � * J. Ii J{ Ji * * A * A A !. !c J. * * Ji
JUSTIFICATION: No request for. a Setback Adjustment shall be granted
unless it is determined that it is consistent with the intend and purpose
of,this Ordinance; that there are special rcircumstances applicable, .to the
property, including such factors as size; shape, topography, location or
surroundings that justify the approval of the adjustment of the setback
requirement, and that the adjustment will 'not be .detrimental to the
;�ealth safety, and general.welfare of the community or be detrimental to
property in the area of the'parcei for which the adjustment .is requested.
FORM.013/CS
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