9512-109 (PAT)LICENSED CONTRACTOR DECLARATION
I hereby affirm 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
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason:
(yl, 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 1.1hj1k,,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.
( ) 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 provisions of Section 3700 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.
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 City to enter upon the '
above-mentioned property for inspection purposes.,
Signature (Owner/Agent) Dale
nir#
r " I.' BUILDING PERMIT
PERMIT•
DATE 12/21/9:
VALUATION S3.192.4XLOT TRACT
JOB SITE ADDRESS 48-521.5 VU AMISTAD
APN 646-122-022
OWNER
CONTRACTOR
M
OWNER -BUILDER
JOHN CONXNGHAM
48525 IVI A AMIS'f AD
LA. QUIN°IA. CA 92253
Cell#
DESIGNER/ENGINEER
USE OF PERMI1,1AJJ0
0PEN :LAT 110E 11AT110 Cit VFR
FEE DESCRIPTION
FEES
PORC;J*PKf1C3 246.00 SF
ESTIMATFA COST OF CONSTRi1f"T1CON
3,192.00
PERMaII FL+'#+' SUMMARY
P1, AN CHECK FFP. 101.-000-439-318 $40.95
CONSTRUCTIONF.F 101-000.418-100 $63.00
STONG 1bi0TK)N FI s - RE, SID 100-000-241-000 $.50
SUB TOTAL CONSTRUC'T'ION AND PLAN CHECK
$104.45
LEIS PRE -PAID FEES
$0.00
TOTAL PERMIT FE.rS DUE NOW
5104.45
199s
RECEIPT
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
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
fVents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
oe
Final
Final
BLOCKWAL A PROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final
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
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)
COMMENTS:
40
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TVIM PNTM CMER
ARCHITECTURAL VARIANCE REQUEST
Unit 8 Oa"te
Street Address - sz
Local Phone /— 210 Z Other Phone
To the Architectural, Committee:
We, the undersigned owners, request your approval of the
modifications proposed on the reverse side of this form.
Att.ached are drawings of the work to be done;,types of
material to be used are indicated on the drawings. We
understand that building permits for home improvements are
required by the City of La Quinta and that the cost of the
permits and responsibility of obtaining.permits and,
subsequent inspections will be borne by us.
W'e' ackowledge that all approved changes in the original
design will be at our expense; that any damage to or
relocation of existing sprinkler systems, underground
utilities, building structure and exterior'landscaping or
other damage resulting from construction of these permitted
improvements will be at our expense; and that maintenance of
the permitted improvements will be at our expense.
Signature of all owners:
t
- Y.
Please pr,ov•ide as:.muche'•detadI
as' possible s'o that the
-Committee may consider approval without delay! -
s
The• above proposYa'1 has ,been reviewed by the Arch'i.tectural
Committeef and' has-been:
-
'APPROVrEO REJECTED
PENDING FURTHER
O
---=
INFORMATION
-O `
+
- Comments.!
DA E
-/ om i t t e e 1
Committee, �' Committee -
c
b e r
�,.
Member, 4 !� Member
.. - 1
+ of , `. ..� _.• r' �
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