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LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing'Wth Section 7000) of Division 3 of the Business and
P'rofes'sionals dode, and my License is in full force and effect.
License # Lic. Class Exp. Date
Date 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). _1 . ---
() I am exempt under Section B&P.C..fethis•reasorl•
ete Signature of Owner ->r'."..:c.,
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 Policy No.
(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 p 4ii'sionsof Seciion.3700 of the Labor
Code, I shall forthwith comply with;those provisions. , r
•Efate: `.4 - Applicant �/ r. • • .� yr. �. ,
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 t
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, indemnity
& 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,.r0presettt5'tives of this City to enter upon
the above-mentioned property of ins ectiop,ur-oses.
signature (Owner/Agent) r` f r' Date
PERMIT #
BUILDING PERMIT,.
,J
DATE VALUATION ,�rty [ LOT TnACT
JOB SITE
ADDRESS ?t�>ti+
APN -
OWNER
CONTRACTOR/DESIGNER/EN INEER
VR-TC�E�.kJ1'#�D���'rTi?rt4�fNA,
��YAF�3"L1- - 3�lidi:x:�ER
F*.�Yt'J TAWEW
A. QY3'J2RA t.AA 922133
USE OF PERMIT
ta.%ng):.6L]3EIn:S iw*(3�
I E4vl.HL.L VU I LK &Jk r"L" K ji-IM I Y' xA 3-I tblVu
VAIXfiXON .2^0,40 La
COi'da` RUCTION FEE 10 1 000-41 8-000 $4W.i39
JTk3.OM T+ftOT1014 ME- REMAD g 0 S -000-2111.000 $ 30
'UYB-. .:01MUCT.t+. X AND :f?TAN C.SD+t-C
$7416
VER VNIAT STENS DITF Nta'In'
TK?5
RECEIPT
DATE. -i
BY
DATE FINALED
INSPECTO
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Fcrms & Footings — _
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
OX 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 - ZJ S
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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:
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)
LICENSED CONTRACTOR DECLARATION
In I he-ety ai'rm ender pena'ty cf perjury tta I am licenser- underpro\•isic-Is of
H 1 Chapter ? (con -.r. arcing with Section 7000) o1 Dhrisien 3 a, me BLsiness and
N r.1)Frclessiorels Ccde, and rcy License is in (ull fcrc2 and ?int' Ex?. Gere
W license 0 .e. Clzsa
W n
it Ir;z Cal= Signalu:eof Ccnl:actor
o r• -
BUILDING PERMIT
:;ATE W.LV,%T,JN .Iit7 LOT
ADDRESS 7�i-,-900 TANGELO
b'.eFt: n4TDP r_.AFENA
PEiir•lrri
:.Ptd
?4C1ORi DE9 3WR r _NGINEE3
O
H CD OWNER -BUILDER DECLARATION ?S-9COT.�. cax) I
u c sLz: 3
W W ieveby atlrm ender penally o' 2arjuni tnat I am e:cempt from Iha Cart actors T -A 2U>i�i �� � )
~ a i_.cense Lav: for Ir -ollcaiing reason:
Z (moi 1. as o:':r.er o' the procartV. or my er-
as 'with ,vages as heir s::,e
6IM-ensation. will do the work, ar.d the str.ctu a is net intended If cierej for LSE OF F_RMlr
sale (Sec. 7044. B!js ress & Pro:essionEls Ccde).
I, as carer of the properly, am exclusively' car:tra=ting with rioensed hE%%M AL-Bi7 .I WO
coctractors.l_ cocslnl the 8 Prciessio pro?=ct (Sec. 7044. t3usir.e<-s _ ,A _1PL I. -
l.
ct) Be
*' am exempt urder S=-cticn B.&PC f Fj.A 5
iva
r -e J 1 O
- ! 3 .:? % Signature s•Naa
f �_ • �r
O� a
U WORKER'S COMPENSATION DECLARATION
a Z �ALVAT)ON
Vr C3 S I '�areb_� affirm under panalP; o1 perjury one of he -ol`O\\�nc declarations:
c� Q ) I have andw. rnaintajn a ceriificale co consent to set` insure tar wor.<ers'
XW - cornpensajcr:, as prcv`ded fcr by S_cticn 3?00 0l ate Labor Code_ tor. he
(� p=rforrr.ance of we wore, (cf vihicn this perr,1.1 is i=sr.ed.
CG Q U ( 1 . have a'�c .\`.i maim?".n v:�r<ers' cornpsnsation inswance. as required by
Code for Oe p=riorrtarce cf he 'nark Ir- v,hich tis
CM.1 �
dU
H
Alto,
S_cton 3700 Of L?Labor -
s issuEd. \T; `porkers' ccrnpensat r. rIV0.�c- carrier & po1Cy na are:
�SI�cI�f lr� CC -ST OF COI`XS�PUr`tIO�
6.
G z.
permil
Car`Er F.- i
YvP.milj' FK2
00 5
PLA- CIIECK I'E�
t' i -G!'� 2 I
l �. _ 9-318
ob a
Q
(This section need not t o ' rnplated it the pert -.d vzlc=_licn is fc- S1oo.Co or less).
We •,vor.i tpr whbh his permit is issued:
Cfs�i i kUL Tit?N c'r?�ar
S45 co
i a i _0011-41 8-,r,CG S45 co
-J
l I cera fy lhal in the pyrrorrrance cl
so Es IO beoorr.e subject to tae
..9TItGaO-MOT101i FP -s^.
• IRYUD ii;l "PIJU'"sa i -000
I rot emF.oy arty person in any manne•
iwo•kers' oc npei5aficr laws of GeU:omia, a�Agre i, s iou
sub'ecl :o the worker cor-nsalan �rsrc•ns of Se-aon '.Acr,'oI.e Lebo'
Code: I'shail fcthNitl• •comply -.1 . a�� ✓
114arnin1g: Failur= to secure W=rkers'J :m.:ensal.on coverage is unla,•,Srl and
shad su=reel an errcio;er :o cem rel pena:ti=s and ch it ines up to s1Cc,o00, in
acecion tc Tie cost of corr.pensa7o:n, damages a=_ provided lot in Section 3706
of 1'ne !_abor COcce. interest aid attorneys fees.
I1v1PORTANT Appfcatior. is hereby pace to rhe Dire=:or of 6ui•.d;ng and Safey
:or E perm l sub:_�I Ir-• rhe con4,lions and reslriclions set`orth an his
a_p1i�5on.
1. Each person Lpon whose oehalf :his apt :kation is mace &each person at
whose request erg ;o• v:hose benefit is performed urger or pj:suant to
ary oe•me. issued as a reE� l c? tii s applira:on agrees to. & sha.l, i dercnity
& mold I•ar-a1=ss tie City of La Ouinta, its cficers, agents an� employees.
2 ?.ny penti1 issu=e as a result of his application t•ecomes null arc void i!
work is rot co nr:Enced \Athi- 190 days from bate of issuance cl such
pe mi!, cr cessal.on OF %%ark to '.80 dais w.11 suC;ec1 p8rmil to c�icellafor.
I ca tit. 1-a1 I ^ave read his apol cation End stare that ire 2bo a infoa ti.1 n s
ioo:reci. I Egree :.o comply with ali CilY, and Stale IF v:s retain^; it Ute er tip -c -r.
con.=:ruction, snd hereby auho izeJePcr?rcvas of ,cr to enter a r•
the atrJe men 1o�e:� pr00Ert-sPcctji, ugtoses /
�5iynature ;Cv:rer+At4e�11 �" _.- .
1 1 0 '603
Ali i
411�ti: �;: LA �I;INTA
fl ±�1�01=D
QT:a_ i 02;°&aTJi iT02�' Pu'�iY C'G
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now ;,7;.. s
MAR -11-2003 12:34
,t4 #
Permit # _& 'k
pV
KRYSTAL KOACH
K Telephone: b d3.i
Stare Lic. it :
Arch., Engr.. Designer:
Address:
City. ST. Zip:
Telephone
r5tatc Lic. 0:
A Name of Contact Person: vlNC
X Telephone s of Contact Person
N Submittal
Plan Sets
Structural Caics-
Truss Calcs.
Energy Calr9.
Flood plain plAn
Grading plan
subcontacror List
Grant peed
H.O.A. Approval
m HOUSE;.
Planning Approval
Pub. Wks. Appr
School Fees
1 714 986 1240 P.02
City of La Quinta .
Building a Safery Division
P.O. Box 1504, 711-495 Calle Tampico
La Quinta, CA 9220 - (760) 777-7012
Building Permit APPlication and Tracking Sheet
EC d L . Owner s N2 me:
Address: % 00 71 NGf'G d
City. ST, Zi 3 �. (j Z 2-
F Telephone:
PTelephone: '
1714
Project Dcscription; r 0.
DGG� Qoo�r F,?^rte X16.
.M
ity Lic, #:
1414.
Construction T t ;
yp Occupancy:
Proicct type (circle one): NOV Add'n Alter Repair Demo
0&Nj* Sq, Ft.: j�yt) Stories: tt Units:
`etZ 3 Stimated Value ofproiect: ea. OIDD . V�
APPL)CANT: DO NOT WRITE BELOW THIS LINE
Plan Cneck submitted
v7h
-...�—..
1'tcviewed, ready for corrections Iqs
)l (�
Called Contact Person
Plana picked up
Plans resubmitted
2" Review. ready for enrrections/issue
Called Contact Person
Plans picked up
Plans resubmitted
Review. reAdy for eorrectiona/IESUC
Caned Contact Pcrsan
17ate of permit issue
PERMIT FEES
Item
Pisa Check Deposit
Plan Check Balance
Construction
Mechanical
Electrical
Plumbing
Grading
Developer Impact Fee
A.1.P.P.
Total permit Fees
AmoUnl
MAR -11-2003 12:35
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1 714 986 1240 P.03
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MAR -11-2003 12:35 KRYSTAL KOACH
F
t
- STS -42
42" Stainless Steel Outd
1 714 986 1240 P.04
U L 5850
,Dor Fireplace
31 [787MM]
00 pII
5/8[16MM] / 231/4[591 MM]
T
a o X11 14 [356MM]
�IMINE
MINE
42 [1066MM]
48 (1219MM]
West End ]Brick N, Fire
1900 S Proforma Avenue
Ontario, CA 9I761
Phone 909-923-4305
42 3/8 [1076MM]
23'/2 [598MM]
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SPECIFICATIONS
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Wwk Weds,
Dcpth
Glee,
Six
Acaml
TFmncng
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Fuming
Actual
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42 LN
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42X23 l/2
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12199 HEAT-N-GLO • (612) MS -6000 • www.heat1glo.com
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OF9w 78-495 CALLE TAMPICO — LA QUINTA, CALIFORNIA 92253
_..
TELEPHONE#60) 777-7012 FAX (760) 777-7011
/BUILDER INFORMATION
Dear Property Owner
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified. i
For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are personally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the ptoper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law to put their license number on all permits for which they
apply,
If you plan to do your own work, with Ithe exception.of various trades that you plan to subcontract, you should be
aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the -State and Federal Government as.an employer,and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's
compensation insurance, disability insurance costs and unemployment compensation -contributions. --
There may. be financial risks for you if you do not carry out these obligations, and these risks are especially serious with
respect to worker's compensation insurance.
For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefrt�Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally or through their own employees, without a licensed contractor or subcontractor, only under limited
conditions. f
A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building
permit, erroneously implying that the1property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing 'their own work
personally.
Information about licensed contractorsimay be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA"I
DEPT. OF BUILDING AND SAFETY 1
78-495 Calle Tampico l
La Quinta, CA 9225
(760) 777-701
FAX: (7
OWNER'S ATURE/DATE
-7q 400
PROPERTY ADDRESS
0304- 114
PERMIT NUMBER(s)
MAR -11-2003 12:35 KRYSTAL KOACH 1 714 986 1240 P.05
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41
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TOTAL P.05.
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WARNING!
fm' pro'per Installation, adjustment, alteration,
!Service'or maintenance -can cause injury or property
da I mage. Refer to this manual. For assistance or additional information, consult a qualified installer,.
service -agency or the gas supplier.
......
A.14
WARNING!
fm' pro'per Installation, adjustment, alteration,
!Service'or maintenance -can cause injury or property
da I mage. Refer to this manual. For assistance or additional information, consult a qualified installer,.
service -agency or the gas supplier.
18-03-2003 11:42 FROM -THE ISLANDS
702 894 9886 T-307 P.005/009 F-231
. ecffilcdoi
OUT42 INSTALLATION INSTRUCTIONS Thefsrst mum in fin via s
A. LISTINGS AND. CODE APPROVALS
This fireplace system has been tested and listed in
accordance with UL 127 standards, and has been fisted
by Underwriters Laboratories Inc. for installation and
operation In the,United States as described in this manual.
is fireplace has been tested anti listed for use with the
optional components listed on page 5. These optional
components may be pumhased'separatety and installed
at a later date. However, installation of a dual cooling air
kit is required and must be installed at the time of the Initial
fireplace installation. Failure to do so may result in a fire
causing property damage and/or personal injury.
Check with your local building code agency prior to
installing this fireplace to ensure compliance with local
codes, including the need for permits and follow-up
inspections. It you need assistance during Installation,
please oontactyour local dealer or the HeatllatorTechnical
Services Department, Hearth Technologies Inc., 1915 W.
Saunders St., ML Pleasant, Iowa 52641(1-800-843-2848).
a
Heatilator® is a registered trademark of Hearth
Technologies Inc., Division, HON INDUSTRIES."�' `� i•.:.
lip
B. DESCRIPTION OF THE FIREPLACE SYSTEM
The Heatllatorflreplace system consists of the following:
a. FireplaceMtegral GratelCooling Air System
b. Refractory
c- Chimney Termination Cap
d Chimney system
e. Hearth Extension
2, optional Components Include:
a. Glass Doors
b. Weather Cover
NOTE: Illustrations used throughout these instructions
reflect "typical installations" and are for design pur-
poses only. Actual Installation may vary slightly due to
Individual design preferences. However, minimum and
maximum clearances must be maintained at all times.
The illustrations and diagrams used throughout these
Installations instructions are not drawn to scale.
Figure 1- Typical Flreptace System
il
18-03-2003 11:42 FROM -THE ISLANDS
7.02 894 9886 T-307 P.006/009 F-231
r.yu.a ... ...... • ............ _ �r...a
Termination Cap
h.,VQ cmhtoi
OUT42 INSTALLATION INSTRUCTIONS
Thefirstnanwwfzre hwa
9. Installing the. Termination Cap
If a roof flashing Is to be used, Install the roof flashing
appropriate to the roof pitch and Install a round
termination cap following the instructions shipped
with the cap.
For chase installations you can use a round
termination cap (TR11), a round telescoping
termination cap (TR11T) or a square termination cap
(ST1175). A chase installation must use a chase top.
Chase tops are available from your Heatilator
• distributor.'
S1o�AOD907
a. Install the chimney sections up through the chase
"'°`°+e
enclosure. When using a TR11 round termination
- -
cap, the uppermost top section of pipe must
t—
rm+n
• extend 6" above the top of the chase collar to allowL
J
installation of the storm collar and termination
L
cap. See Figure 14a.
raft O imf
b. For installations utilizing a TR11T telescoping
round termination cap, the uppermost chimney
section must be below the top of the chase top; '
but not more than 1454" below the top of the chase
top flashing collar. See Figure 14b.
c. For installations utilizing an ST1175 square
termination cap the last chimney section must ;
Figure 149 - installing a TRt1 Round Termination Cap
not be more than 454" below the chase top. See
Figure 14c.
d. Attach the chase top to the top of the chase.
e. Install the termination cap, following the
instructions provided with it.
'
r.yu.a ... ...... • ............ _ �r...a
Termination Cap