0112-135 (PAT)1.
. • .. -. . r ., t . M
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions,pf
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
7939138 C6I x.'03 n 2,r 04,1:30/2(:
Da et =J_/-?' -:, (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.
(yt)/f 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 iss Ze�d.ItiMy yvorkers' compensation insurance carrier, ptoo�oyAno. are:.
Cartier 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 ovisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions. -%
Date:/ -,"N. o "L sY Applicant ,a ... 1 s�
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
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 Cify,.'io enter upon
the above-mentioned property for inspection purposes.i
Signature (Owner/Agee) �^- - ^' Date ' jy ..�9 (�
I ..r: v a r+ i
PERMI�T�#A
BUILDING
�PrERMIT
DW?E 1211 ?MX VALUATION $3,V5XA0 LOT TRACT
JOB SITE 4 -�i�&-S'b�l.I�➢O�.TiY M
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
PAT CUIC TS
01011AI AM SC VA11 MED AWN"WO
43.60 TIiiihlC S Uf
60-661 1.MAX;is',i Y CZ
uo . Quimm CA 92253
INDIO CA, 92201.
(700)347-0592 Ci' ILO 4996
USEPOF�P�E1R0IT
art• i[rrp s r r an rr.v • r� H rrl{ .'s - snm re. r.ne+o� X140
a. �
PORt 13/,ir,ATIO SP
FSAT"TrD COST OF CC3S'1'SIIMCM1 .C3m
PI1hN CSI- EI CK FTSE 101 -Qt -000439-3118 $40,91
GONS'PI2Ysf:'f`1 N I< � 101-000-418-000
x1�o s 0�`i0 • 6 - RESID 101.000441-00
f
DEC 1 i 2001
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T OTAL PERMff FUS ME NOW
3,104A5
RECEIPT
DATE
BY,%�
DATE FINALED
INSPECTOR
.J
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 8 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
Fbdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
jp=
STARLIGHT DUNES �.
HOMEOWNERS ASSOCIATIONAEPI
OR AQrwITCt—n it..
DATE:
OWNEWs NAME: I v e vR-T-11
r,r f'iaONE• 7Lo .�j0 :3�7y
PROPERTY AddRES5: 6 �aU -
ModifiCATION REQuesTEd:ZiUtrU Cover
(REPAINTINCE Of HOUSE dOES NOT REQUIRE dRAWiNgs SUbMITTEd OR PERMITS}
TO: ARCHITECTURAL / LANDSCAPE REVIEW COMMITTEE
YOU ARE HEREBY AdvisEd T6r Ti,c AboTrE walk is I
TO SCALE (MINIMU_M,I_') Of The WORk-TO bE'doM- d- Is
AppROVAI i5 REOUESrEd. ATTAC(IEd ARE dRAwiNe s.
wdwawiNgs. WE UNdERSTANd THAT BUildiK PERMITS foR soar �ryp'ES TIONS ARE To �d ARE 1NdiCATEd ON TkE
OviNla ANd THAT THE COSTS Of THE PFRMiTS ANd THE RES REOUIREd by AE Ch Of LA
iNSPECTiON will bE boRNE by THE P ibiliry Of ObTAiniNq PERMITS and subseouENT
WE ACkNOWIIEdgE TIiAT All AppRovEd C(�{giy '
OR RELOCATION Of V"ST'Nq SPRiNkFER THE ORIgINAI dESIgN will bE AT OUR EXPENSE; T{tgT ANY daMAgE TO
TO OTHER dmm T A SYSTEMS, UNdERWuNd UTiliTiES, bUILdiNq STRUCTURE ANd ocTFAOR (ANdSCApiNC�
�jE 0 550CIATION PROPERTY RESUITINg FROM THE CONSTRUCTION ANNOR LNSTAHATiON Of THESE
PERMITTEd IMPROVEMENTS Ball be AT OUR EXpe4sE.
WE ACICNOWIfdCsE A $ECURiry DEPOSii Of
-10%
0%-20% NONE Of THE TOTAI COST Of THe
REOUIREd TO COVER ANY dAMAgF TO TILE COMMON AREA OR. CkAN_Up nECES5ARY f0R TFIE COM �E� IS
DEPOSIT AMOUNT Will be dETERMiNEd by THE ALC IN RdATiON To THE EXTENT Of THE WORK. TME Of THE pRojECT.
&POSITEd l be
TO COMMENCEMENT Of WOR(I. AFTER iN5PECTiON Of TILE COM EIEd Ro ECT POscT MUST be
dEposiT will bE REfUNdEd if AU PI P 1 by The ALC, ThE
**NOTE: CONSTAUCTiD Ny7AIIAT1pN ARE R@STDREd TO ORIgiQ OR bET w CONdiTioN. '
RECEIPT Of WRITTEN APPROVAL ANd ON f MueSTEd ANd APPRoved MOdifIcATjoNS MUST bEgrt WITHIN 4 S dAys of
PRioR TO COMMENCEMENT Of RO adifImodificArioS MUST be Ca►TpIETed W ThiN 90 dAYS Of WRITTEN App AL
BOW ANd Copy Of LICENSE if OTtmpt T6.4 HQmEOwMER MSSTPIESAIIAAo IT Fa,IURE'TppplrCA wi T TiiESE�NNSUR►NCE,
ABOVE SpECifiCATioNS will REwIT IN THE NUIIihCATiON Of TRIS dOCUMENT ANd Y Of THE
ENT ROVAI THEREOF.
-OWNER SICNATUR •
AM bNq AddREss
Scrod To: PHONE 4i dA z
PERSONA zed PROPERLY MrmT- EVENiNYjS
669 10 AdE(iNA ROAd
CArHEdRAI OTy, CA. .92234
ATTN: ALC ComkiTLEE
. t�tttrt.r.trtttetttr♦ TkE ♦ttAttAAr Artrttttttrrt trfrt Att/fA.AA1 AbovE aEOutiT HAs bREVi EEn Ed
by rk ALC and (gas btEn: 'APPROVEd () dENiEd ( ) pEndiNq
E
DATE RIMEWEd-
AppRovEd By: DEPOSIT AMOUNT:
{MUST HAVE TWO (2) SignATURES)
fE
I
dBW :BO TO t►T OaQ
LFApp�yi'n,'
/..'r'. .
CITY O F LA C� U•I IA
BUILDING & SAFETY DEPT
PPF
FOR CO 13
DATE Z r By
SuRti-Ni oCR£L» & AWNING CO.
46050 :CALHOUN ST;
INDIO, CA 92201 ..
(76`1 r, -AX (760) 775.5434