0109-187 (PAT)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 of the Business and
Professionals Code, and my License is in full.force and effect.
License # Lic. Class.. Exp. Date
Jr Kr P
Date fib, Signature of Contractor L<^- Y•+` /�
.1„
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 370,0 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 Policy No.
; FATE FUND
(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 all fo hwith comply with those�provisions.
Date: a / h Applicant \ y_"_, a
Warning: Failure to secure Workers' Com ensation 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 purp ses.
Signature (Owner/Agent) %%- Datew2/�
7 '
BUILDING PERMIT PERMIT#
DATE VALUATION {. LOT TRACT
JOB'SITE
APN
ADDRESS
4a.4.25 CIA.LUE SERANAN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
WAVI P,. . t0-MO2,
TONY 14 YBARRACONST. CO.
48.125 C Y.LE ��,d.MNS
LA. QMvTA CA 92253
C'OS"iF..MESA CA 92,626
(734}979-5.93 CM4 11.,240
USE OF PERMIT
lWiao
PATIO COVER
POl1MPATIO 119.00 9
:"570,1ATED cour R?p4 8rommu4r""fu?1`8'
P401 O.H&OK FRE 101 -000-439-418 $24,05
C;r;3t•+1STRUC'TION FEE 101-000-416-000 $37,00
FFORM(/ MC 'f,'40N FER :. FE. 'a".0 101-000-7.41-000 `3,50
SEPgNT
CITY FIN
315B 'A (YI-AIL COM rMUM ION A90 PLAN r,$WCX
LESS PRE -PAM ld�UI
�1),C1t3
r
dF'6s rAL I'.�J'A9.7!Y1137�8}EP.1, DUNHOW
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
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines 1
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
�f!/w
_
Final qti�� o sZ
BLOCKWALL APPROVALS
Final
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) f
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Lary Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
• � J
ARCHITECTURAL COMMITTEE CERTIFICATE
(Exhibit "A" to the. Architectural.
Improvement• Application and Agreement)
The Architectural Improvement Application and '.Agreement was
reviewed by the 'Architectural Committee on and has. '
been:.
Approved Conditionally Approved Rejected
subject to the following `
condit-ions set forth below
Returned for .Further Information ,
r
Required Modifications
Comments
Yes No
Recording to be :sent by owner to County Recorder's
office for roof and/or exterior wall modifications.
Deposit Required Deposit Amount Required $
Da e Architectural Committee
Ar itectiural ommit ee - Architectural Committee
Arc tectural•C A ittee Architectural Committee
NOTE: THIS A-PRO AL'.IS VALID FOR 90 DAYS FROM.-APPROVAL DATE m
Rev. 4-96
EXHIBIT "1"
ARCHITECTURAL IMPROVEMENT APPLICATION AND AGREEMENT
DA E�
NAMES)
STREET ADDRESS
LOCAL PHONE 77/ /�qf OTHER PHONE
REQUESTED IMPROVEMENT
o
Approval is requested for the above improvement according to
the plans attached. We have attached two (2) sets of plans
outlining the work to be done along with a complete description
of the materials and colors to be used. If we are using a
contractor(s), we enclose copies of the Contractor"s License.
Attachments:
(1) Two copies of the Architectural Improvement Application.
(2) Two sets of plans with materials and colors to be used.
Note: One set is for the management office; the other
set to,.be returned to you as "Approved".
(3) Contractor's name. and .copy, of .contractor's license. (Not
required if the improvement is under $300.00 or if
"Owner -Builder").
(4) Brochures (2) and/or color samples.of manufactured products
to be used.
We have read the Architectural Committee Rules and Guidelines
and have furnished copies to all contractors to - be engaged by
us and we .agree to comply with .those Rules and Guidelines.
We also understand that it is our responsibility to insure that
our. Contractor(s) comply with said Rules. We acknowledge that
Building Permits for home improvements may be required by the
City of La Quinta. 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 in compliance_ with applicable building codes including., but
not limited to, those adopted subsequent "to the original
completion and acceptance of our dwelling.
Rev. 4-96
Page Three
We further agree that this improvement will be completed in
a reasonable and diligent manner. 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 I allowed time frame the Homeowners
Association may elect to complete the work and/or repairs, and
we will be responsible for the actual costs of such
uthework.
Pof ent
at
to the Association is authorized by
assessment or monthly penalty payments as approved in the
Guidelines.
By signing this Agreement below, we agree to be bound by its
terms and, conditions and any
Architectural Committee in
Certificate, which is, attached
a part hereof by this reference.
Signat a of a 1 Owner
(Srignature)
conditions set forth by the
the Architectural Committee
hereto as Exhibit "A" and made
(Signature `