9605-072 (RER)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. r•
" Licerise #' '' Lic. Class Exp' Date ^ ,
t1 il'is3 A B 1.. f i/101,111
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!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, wilr do the work, and the structure is not intended or offered for
sale (Sec. 7044, -Business & Professionals Code).' '
( ). 11, as owner' of the property, am exclusively contracting with licensed
contractors to construct they project (Sec. 7044, Business: & Professionals
Code).. 11 -
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner' f
WORKER'S COMPENSATION, DECLARATION
I hereby affirm .under penalty of perjury one;of;the following declarations:
O 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 bf the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of,.t%e Labor Code, for the performance of thhe„work for which. this
firAtr (rrtitl 111 rvi
permit is'Issued. y workers' compensation insurance camer 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!provisionsof Section277009,of e Labor
34de, I shall forthwith comply with those provisions
!Date: i t1 9(_' Applicant, . ,� _ p,,;!`�
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 of 4
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 1"�-
& hold harmless the City of La Quinta, its officers, agents and employees.
I 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
Ke above-mentioned property for inspection,purposes, /21
/t ' orf �f ' s '' -2 �� '�A
rSignature (Owner/Agent) /�'� �' Date
y',
' BUILDING PERMIT0.
PERMIT9# CONTROL N
.073234
'r '
DATE :5115/96 VALUATION ,'97.752.00 LOT
TfiACT ,• r
yt
JOB SITE 54-615 S0111 i"r111111S ,.r
y..+:n:.•
APN '70-451-433
ADDRESS
OWNER
CONTRACTOR / DESIGNER / ENGINEER
�.:�t�,�.��',�:'a�r�',�»' ..'
.• c:�s�:.�;'�r'�r%+t,r',�.%.si�t�i' �.fli�a�t����,rc�itt.
54015 SC3ViRMAi KS ` :.
5095.5WASWNMON ST,
LA QUftNTA CA 92i53
LA QUIN 'A CA 922.53
stato2�
USE OF PERMIT
RIPS,7Dr, TIM, 1eE )D.F:1°
LNC,C_)SE E l[S7`47:3t31;'Ct'1ME01`ATICJ
'i�:lttlti"!' N'1"�t� i)f�lilt�'t�lF1J .
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F>Lt1,Af +v.'HECK 11th 1011.4)00-X19••3-1.8
U4.3
14F(,' 1A'N1.CAL
NS15.00
:Hfafya °iat'cM. Fer.
$19120
3T0NCVMUT.1QN1 M "(FSHD 101-f 00-241-t))
$.78
_
SIYB': FUr.AL CONS'.fP UC7flON )SND PL..AN EC.W- -,
$108.31
� LESS PRE -PAID FEES;
0.00
^
/
OTAIL PERMIT FRIEN DUE NOW
T
RECEIPT,/' `» r"
DAT,E/
BY t
DATE F ALE
INSPECTOR�,�'
i
5 30 6
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
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final EE�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
Final
UU14 Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduft'
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)
COMMENTS:
COACHELLA VALLEY UNIFIED SCHOOL DISTRICT -
CERTIFICATE OF COMPLIANCE
(Government Code 53080),;'-
Project
3080); -Project Name:
54 -015 -Southern Hills, La uinta PGA
Project Address: 4 � • _ _
Project Owner's Name: ; .Chang A Stein Phone No.: 771-1877
Project Description: Remodel=Custom
Building Type, (Check one): y' Residential xx (Include No. of Dwellings)
Commercial Industrial `
Tract No.•Lot No.: '
(If tract, attach Schedule "A" of all lots by tract, square footage for each lot and total.)
Assessor's Parcel No.: b
(If Schedule "A" is used show Assessor's Parcel No. for each lot if one exists or Assessor's Parcel No. for, parcels before subdivided.)
Total square feet of'Building Area: 7,752 Sg!Ft,f +�
Certification of Appiicant/Owners. The person signing certifies that the above information is correct and make's
this statement under penalty .of perjury and further represents th she is authorized to s' half of the
owner/developer.
Dared: S I Signature: .a.
f City/County, Certification: JG `
(Signature) Optional
(Title)
� RRRRRAAAARRRRAR#1kRAAAAIkfkRf4flftAAAfIAftAAAR7tRRRkAAAItRAARRAftAftAAAAAAA1klftfeftRlt4lrtARlfktkRRftfkAAfIRAAftRfeA
SCHOOL DISTRICT REQUIREMENTS FOR THE' ABOVE PROJECT HAVE BEEN OR WILL BE
SATISFIED IN -ACCORDANCE WITH ONE OF THE FOLLOWING (CIRCLE..ONE):
Gov. Code .Gov: Code Project Agreement Existing Not subject to fee
53080/65995 65970. Approval prior to 1/1/87 requirement.
Note:
Pursuant to AR, 181
�a• ' F Developer fees ,can only be assessed
' • on new construction.
'j Total Number of Sq./Ft. 71752
.Amount per Sq/Ft. $ _o -
Amount Collected $ M -0 -
School District Official : s Title: Asst. Suaerintendent Administrative Serv.
Foch "Tut" Pensi
Date: May 1, 1996 Phone: (619) 3995137, Ext. 235
Note: AB 2926 and SB 20.1 fees are capped at $1.84 per square foot for all residential construction, and at $0.30.
per, square foot for commercial/industrial projects.
ARCHITECTURAL/LANDSCAPE VARIANCE'APPLICATION
PGA WEST RESIDENTIAL ASSOCIATION, INC*
Please complete and include this request form, along. with
four (4)sets of'your proposed ,home improvement plans to:
,PGA WEST RESIDENTIAL ASSOCIATION, INC.
P.O. Box 1060
La Quinta, .CA 92253
or,. 55-940 PGA' Boulevard
La Quinta, CA 92253 }
Attn:. Property Manager
i
NAME: DATE:
ADDRESS: - 5ZF
-
PHONE : —g 7 UNIT
PROPOSED STARTING DATE : , - .Z 6, -
APPROXI COM
Homeowner's Signature
The followingappropriate ••
accompany you
information should r
completed application:.
1. Four (4) sets of complete plans to include
a. Improvements and/demolitions"
b. Plot- plan .
c. All dimensions proposed
d. Relationship to neighboring units'
e Materialand color scheme ,
f... Planned modifications of all external systems (landscape,
sprinklers, gas lines, electrical, etc.)
2.' Agreement and Covenant Running with the Land completed and
'notarized. Two_(2) original.
3. •Conditions of Approval.and Disclaimer form•(signed)
4. Facing and Adjacent Neighbor form (if applicable)
5. Construction:;Regulati'ons form (signed)
ELECTRICAL [ ] Approved [ ] Disapproved
Signature Date
LANDSCAPE [ ] Approved [ ] Disapproved
Signature Date
ARCHITECT OMMIT E [i A sY
pproved [ ]. Disapproved
Signature Date
�(5hL
• � •
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ROB+ERDES RESIDENCE
54015 Southern Hills, Li Quints
subject:. .
STRUCTURAL CALCULATIONS &
DETAILS
for Shearwall Replacement
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