9905-164 (AR)C'W4,
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t 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
13 r� f'iitil30(1
RSD-"lSignature 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 exempeunder Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
( ) 1 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.
(JC) 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.
STAIM, FUND ril -;Va 11Nff 01392
(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 37.00 of the Labor
Code, I shall forthwith comply with those provisions.
/Date: Applicant
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. It
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 thatfl have read this application and state that the above information is
correct. I�gree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the.,a'bove-mentioned property for inspection purposes./ l
/Signature (Owner/Agent) _ ���� -� - Date -,
BUILDING PERMIT PERMIT#
DATE VALUATION4.���. LOT TRACT
re _
JOB SITE]y' �' (,�
ADDRESS ��}39,SOUTHERN 111(1:Rl.dRy
APN
769-451-035
OWNER
CONTRACTOR/DESIGNER/ENGINEER
NOR MAN 1 LH VE !
MP QUF1i.rrY t NPI.PE';hi'l RX
34039 SWIVERN HILLS
67660 CLU13HOUSE RLOA17
LA QUfNTA. C•A. 921.53
IXSF.R"i• KCyr SPR NGt CA 92141
(7601 151-0037 0131.4 5324
'
USE OF PERMIT
U SdT.► 1A1'1As Ai3l.i.! l(>N
64 sx. -,Roo 1 A13 )1'aoN
WiT.OW CO I ,TMICr11O tii &I.00, SF
ESTMIr"sTE1) C<L311T OF CONSTRUCTION
4."5.60
1?'r���iM.ITFE S1:[1lIMARY
PLAN C",I f,/ -*K FEE 101-000-4 9-�18 $46.80
f°r finfS'T,�ti,iG i iF3td { Imo, ;09 t}tl-A16$-01 sr".00
llfi CHANICAL-h--11 101-000,421-000 $14.01;
r:1:WMIC.'AL `P'01 1410 -420 -OW S26.24
STRONCi'IMOTION FTHE - RESID 10:1.000-141-000 >gst
:s
,;1J13-TQ1',,AJ, COM;. i SUC`1'1C:>N AND 1'i.,AN CIMCK
StiF+f1.54
LESS PlIE-44XI 7 FEES
TOTAL PiL41MYT FE. 08 DUE NOW
$160.54
RECEIPT
t
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
S
Combustion Air
Roof Dec
Exhaust Fans
o 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
POOLS - SPAS
BLOCKWALL APPROVA S
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)
Coachella Valley Unified School District
P.O. Box.847, Thermal, CA 92274,
(760) 399-5137, Ext. 235
This Box For District Use Onl
DEVELOPER FEES PAID
AREA:
AMOUNT: RCPT N:
CK N: CASH:
RJIT[AIS: DATE:
CERTIFICATE OF COMPLIANCE
(California Education Code 1.7620)
Project Name: Date: May 121. 1999
Owner's Name: Norman J. Leven Phone No. —
Project Address: 54-039 Southern Hills, PGA West, La Qui nta, CA 92253
Project Description: Residential Addition:t
APN: 769451 035 Tract #: Lot #'s:
Type of Development: Residential
X'X Commercial
Total Square Feet of Building Area: 64 Sq. Ft.
Industrial
Certification of Applicant/Owners: The person signing certifies that the above information is correct and makes this statement
under penalty of perjury and further represents that he/she is authorized to sign on behalf of the owner/developer.
Dated: Signature:
rrs•,►,err#,►,r•,►***• r*,r ,rr+r••,r,►*•#.•*
+rs
,►,►,r+rs.,r**+►+r*•,r•*.****+r.w
SCHOOL DISTRICT'S REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE SATISFIED IN
ACCORDANCE WITH ONE OF THE FOLLOWING: (CIRCLE ONE)
Education Code Gov. Code Project
17620 65970 Approval
Number of Sq.Ft. 64
Amount per Sq.Ft. $
Amount Collected $ 0
Agreement Existing Not Subject to Fee
Prior, to 1/1/87 Requirement
Note: Pursuant to AB -181 any room addi tons
or enclosures ot bUU sq.tt. or less, are
exempt romeve oper ees.
By: Foch "Tut" Pensis. Assistant Superintendent Administrative Services
Administrator in Charge '
Certificate issued by: Marcela Valdez Signature:
aci i ies Clerk
Section 66020 of the Government Code asserted by Assembly Bill 3081, effective January 1, 1997, requires that this Dish provide pp ovide (1) a
written notice to the project appellant, at the time of payment of school fees, mitigation payment or other exactions ("Fees"), of the 90 -day.
period to protest the imposition of these Fees and (2) the amount of the fees. Therefore, in accordance with section 66020 of the
Government code and other applicable law, this Notice shall serve to advise you that the 90 -day protest period in regard to such Fees or
the validity thereof, commences with the payment of the fees or performance of any other requirements as described in section 66020 of
the Government code. Additionally, the amount of the fees imposed is as herein set forth, whether payable at this time or in whole or in
part prior to issuance of a Certificate of Occupancy. As in the latter, the 90 days starts on the date bereof.
TM
PGA WEST
RESIDENTIAL. ASSOCIATION, INC.
April 19, 1999
Mr. Norman Leven
54-039 Southern Hills
La Quinta, CA 92253
Dear Mr. Leven:
Your request for an architectural variance has been approved by Don Adolph, Architectural
Committee Member. Specifically, you have the approval to proceed with the room addition at
your, 54-039 Southern Hills 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 it matches the
original request. - An approval is based only on the aesthetics of your proposed change 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. Should you have any,
further questions'regarding this matter, please feel free to contact me at the HOA office, (760),
771-1234 extension 15.
Sincerely,
v
Ke cGalliard
Operations Manager
cc: Architectural Committee
Enclosure (1)
P.O. Box 1060, La Quinta, California 92253, Telephone 760-771-1234 FAX 760-771-5125