0207-116 (GRES)LICENSED CONTRACTOR DECLARATION
I li*reby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Gode.. and my I ir:anee is in fi ill fnrC@ and affect.
License # Lic. Class Exp. Date PP
Date £r"t, Signature of Contractor �' a., t •';�0) '
i
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 F `G r.. Signature of Owner :r +.•a ` '�•
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.
t).A'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 STATF, PUN.ID Policy No. X46-$010601
t
•k
(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
,C ode, I shall forthwith comply with those, provisions.
Date: v t._ Applicant—
Warning:
pplicant 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.
BUILDING PERMIT PERMIT# 07 iIt
DATE VALUATION d," =220 LOT TRACT
drn4ya
JOB SITE
ADDRESS SMS TANGL�..'' WOOD
OWNER
MKE:�,1a ��yy ��¢�a�pp' yq�qq
54448 1.['l3Y G4cP�f 7w OO.lai,
LA QUOTTA
USE OF PERMIT
e AWE OR CAORT
APN
CONTRACTOR/DESIGNER/ENGINEER
7.7091 COUMY CLM D 4 Ef'M AA -2
0—h 922S3 RADANEWRT CA 92260
(76CY3160.8453 CNAA 490
SPD - 117 SQ.Ff. C OLF C.',JS RT MR.408
0ARAOFICARPOIRT
117,00 OF
E919 'IND OOT 0217 C"OINYMUCT10,1%
MAN C:'3^1ICK ft"t 101-000-439-33 8 ta.S..I E3
CC7Ai:aPd3LfC'4`.i01i
101-000-418-000 ji�4.U0
ELF.(,' `PJ0A1, FEE 101-000.44-0-000
ST 8:ON O A1f0•f'1C+N FEE • R +SID 101-000-241-000 9 so
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 persori at
t
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
o
work is not commenced within 180 days from date of issuance of such
100
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
�V,N"(P►
correct. I agree to comply with all City, and State laws relating to the building
G((�( OF EpE�•
construction, and hereby authorize representatives of this City to enter upon
�ppq,C
the above-mentioned property for inspection.purposes.
R
DATE
Signature (Owner/Agent) t o1. "' 4 _ Dates
014MINMOK Ahs' aYCCN, 2.85
S2 PRE-PAW',U-Mi S0.0o
:AL 1'1U3 11711IMS)JUENQW
r
$x112,85
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 A'L
F.A.U.
Framing i
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath 0
Final
FinalPOOLS-SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
i
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:
�%��� �!�/v/�i4�`✓
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)
June 10, 2002
Mr. Mike Rafter
54-448TarigIewood� -'
La Quinta, CA 92253
Dear Mr. Rafter:
Mr. Don Adolph, Architectural Committee Chairman has approved your request to install an
atrium enclosure to be used for golf cart storage at your 54-448 Tanglewood residence. Upon
completion please submit the enclosed Notice of Completion form to this office.
We reserve the right to make a final inspection of this change to make sure that it matches the
original request. An approval is based only on the aesthetics of your proposed plan and should not
be taken as any certification as to the construction worthiness or structural integrity of the proposed
change.
We appreciate your cooperation in submitting this request for approval. If I may be of further
assistance, please contact me at the HOA office, (760) 771-1234, Extension 15.
Sincerel
Pl,
Kelly cGalliard
Operations Manager
KM/sno
cc: Architectural Committee
Enclosure (1)
P.O. Box 1060, La Quinta, California 92253, Telephone 760-771-1234 FAX 760-771-5125