0110-283 (AR)LICENSED CONTRACTOR DECLARATION . r
�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
• { 4 - - ,- 030 144
/A
1Datel' V Signature of Contractor—
OWNER-BUILDER
ontractor J
da 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's 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,perjuryone 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. '
.SW,4 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" gTATP, F'4ND Policy No. 420.99-D0196*2
(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 a� eye that if I s buld become
subject tp thelworkers' compensation° p odI icns,bf Section 37 /of the Labor
Code I II ,o hwith comply with" f�hos ptovtlslolfi
Date: , {{{ f Applicant
Warning: Failu-re'to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages-as'provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions ,and restrictions set of
on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant,to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is no4 commenced witbin,180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to'the building
construction, and hereby authoriz repyesentativ�e,$of this City to a ter ?pon
the above-mentioned property for`in�spection purples.
t;
Signature ,(Owner/Agent) w�_' Date
It
l
PERM'T# .
BUILDING
.PERMIT
DATE VALUATION LOT TRACT6341-4
J tYg.r6e•. PV
i Lid 2, G� ,� �.. `
JOB SITE.
ADDRESS ."�S•wQ9 �N��11''i➢aJ ee Y
APN
OWNER ti.
CONTRACTOR / DESIGNER / EN (NEER -
k2s3.F.i�',.f?.1'+�''
��^`493 anti:����',4$+`•�i.`:.j.'��1€�.:€�°
i�1���U�'�r�r't`�iY�I�.��e��
Tia QLUNTEA CA 92253
LA. (gllWTIA CA 922$3
t3;ir3'P3n793 C�.if 32.1
USE OF PERMIT
REIVIDWYLKLAUDYPION
43,W? A)30111(ky TO L1V9t-0AR€ V60 3F'.;9.DVITIGN TO Cft„i3.E4.CIE
CUSTOM.CONSTRUC'iWN 4100 101F
OAi4Aii.FWAitPORT 60.06 SF
KO COST OF C4311r4r"t`HLKP1'1.0N'
4,525.'K'1 '.
pky��aY"nVA"I
,SC .L..r.0.isi'd�„A .Y.yv�+►5. �,SL1�,hM1A48.
.
PLAN CHECK F1101 101-000-439-31 8
a9MISTRUCT10 F'8Z - 101. -(W).4 "id.0
ELioTrtw.r Vyz 101..x. 00-420.000
STRONG Ft90"f`10N ?W8.1~ 9S1O 10.1-000441-000
OCT 29 2001
CITVOF A
(FINANCE DEPT
90 TOTAL CC9NGTit1't_7� 0i4.qID PL; -AM 64900
$146.12
11:'G>fAL',PFR1 V1=1 NOW
9146,12 ' ti
r
r.
RECEIPT
DATE
BY
D E F D
I PE TO
'•x
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings _
��
Ducts
Slab Grade
Retum Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing �Q�
Compressor
Insulation 2/'/�� �f
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall _
Exterior Lath
Drywall - Int. Lath
_
Final '3/''(��
Final
_ _
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
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)
Bin #
L
Cit! of La Quinta
Building 8i Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, CA 92253 - (760) 777-7012
PBuilding Permit Application and Tracking Sheet
Permit
�((p�
Project Address: 15 --� S [
Owner's Name: M2 -
A. P. Number:
Address:��/� Off'
Legal Descripti
City, ST, Zip: QUtV04—
Contractor:
z
T eleP h one: 6• s 8
S � �
.............................................
Address:
cS
Project Description:
City, ST, Zip:
W l -W
Telephone: —71"33"
6. d
State Lic. # : &��
City Lic. #:
t
Arch., Engr., Designer:'
i.-,otom. D IJ I
S. .
Address:
fj�& S —
ftvrI C
City, ST, Zip: (lliL
-
. Telephone:
State Lic. #:
S C O
Name of Contact Person:G
.............................
Construction Type: Occupancy:
ane Y
Pr oJ ect e(circle one): Neww Add' n Alter Repair air Dem o
Sq. Ft.: #Stories: T# Units:
Telephone # of Contact Person: 775
Estimated Value of Project:
2-5
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets -
,gyp W
Plan Check submitted
q
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance
55.
itle 24 Calcs.
ap
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2nd Review, ready for corrections/issue
Electrical
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
S.M.I. ,
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, ready for correctio issue
Developer Impact Fee
Planning Approval
Called Contact Person
l 6
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
School Fees
Total Permit Fees
f ` Desert Sarids'Unified School District ;
47-950 Dune Palms Road _ Notice:
La Quinta, CA 92253 , .
Document -Cannot Be Duplicated 760471-8515 ,,
CERTIFICATE OF COMPLIANCE ,
Date -10/26/01 APN # 769-830-0211
No. 22616: Jurisdiction La Quinta
Owner NameRobert & Vera Brown Permit #0110-283
No. 55-495" ' Street Southern Hills
Log #
City La Quinta Zip 92253 Study Area
v Tract #'28341-1 Lot # ' 5" Square Footage
Type of Development Residential'Addition No. of Units 1
y .
Comments, ,
' 4
At the present time, the Desert Sands Unified School. District does not collect fees on garages/carports, co�ered-
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It
has been determined the above-named'owner is exempt from paying school fees at this time due to the following reason:
Residential Addition 500 Sq Feefor Less
EXEMPT -
This certifies that school facility fees' imposed pursuant to Government Code 53080 in the amount of
0.00 X 43 or $0.00 the property listed above and that building
• Permits and/or Certificates of Clccup'a'ncy Occup'a'ncyfor this square footage in this proposed project may now be issued .
�-
Fees Paid By EXEMPT -.Bob Edwards ; Telephone 760-775:7933 ..
Name on the check
By Dr. Doris Wilson
Superintendent,
1
Fee collected /exempted by Annette Barlow Exempt $0.00
Check No:
Signature
[No
TICE: Pursuant of Assembly Bill 3081 (CHAP 549, STATS. 1998) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
bove willbegntorun from the date on which the building or installation permit for this project is sssued or on.which they are paid to the Districts) or to another public entity authorized to
ollect them on the DistrictCs)(s') behalf, whichever is earlier.
Collector: Attach a copy of county or city plan check- application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy - Applicant/Receipt Copy - Accounting
FROM MONARCH FAX NO. 7607765112 Oct: 26 2001 03:59PM: P1
PC;A WEST II RESIDENTIAL ASSnCIATION, INC.
P.O. BOX 1282; LA .QIJINTA; CA .9225.
(760)1776-5 iOO FAX' (760);776-51 I
Pay
QC A/�A
July -19,2001, 2 6 pEC p
Dr, & Mrs' Robert Bror. a
1079 Lombard Street,
San Francisco, CA 941:: y
Reference. 55-44; Southern lElls, La Quinta, CA
Archiiectural Change Request for Golf Can Extension, French Door Modification and
Bumf; •3ut Wall in Living Room
Dear Dr_ & Mrs. Brow...
The Arcliiteolural Committee reviewed your plans for a golf cart extension and French door modification
and bump -out wall in tl:c: living room and approved your application at its July `10, 2001 meeting.
Review by the Committee, is only for general conformance with the architectural guidelines. It is the
responsibility of the owzzr to fully understand and conform to the architectural guidelines criteria whether
or not all deficiencies a`:. noted during review: It is also the owner's full responsibility to field verify all
existing conditions. The: Committee's decision with regard to project design will be final. Please refer to
the Architectural Rules for all required submittals,
`Please contact Raphael Villareal, supervisor for Valley Gardening Service at 760/399-1844 and Carol,
Fuller, the As�ciation _'vfansgcr, prior io any irrigation modifications associated with this change., Upon
completion of changes; ;please contact Carol Fuller. Damage to the landscaping, i.e_,- shrubs, trees, flowers
.and turf, is the respom.bility of the contractor. The landscaping must be brought back to its' original
condition when the prq,1..ct is completed
Approvals given by the Architectural Committee are good for only six months from the date on the.
approval letter. After t1!;it time a new application must be submitted.
Upon- completion ofyner project, please complete and* return The Notice of Completion of Architectural
Change_
if you have any additio:al questions or concerns, please do not hesitate to contact Carol Fuller, Association
Manager, at 60/776-5 =.00, Ext. 20,
Sincerely,
PGA WEST lI RESIDE' ="I1AL ASSOCIATION
For the Archifectural Cummittee
Carol Faller
Association Manager
cc: Board of Dir6_�-jrs
Unit File
l