0209-186 (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.
License # A Lic. Class Exp. Date
ail 14;33 ()5/31{21(
:Date `! `" '' •Signature of Contractor �;1 ` 4 ' ` bR>
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.
1,(1) 1 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:.
Cartier 3TA:Yy' FUNL) Policy No. 046-02*09609
(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, l shall forthwith comply with'those provisions.
Sate: 'Applicant—
Warning:
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 -arid fox 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 City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) ` Z:, -s: �r"r' .�r'�.' N �� '•�"'-•y�'�'�Date�•'' �'��� -�" �:'_.
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BUILDING PERMIT PERMIT#Ar �
t7.�Yi�•-1,E3Ev
DATE VALUATIONS LOT TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN INFER
1�1:LLt".i� 1.Kt;1.��.�'t�'I"1"�
i1���,;r.►R.r��'�. !�'���1:°t.:�Taisr �: �.�:'�,�•, %A
4.8.541 1AAk1vWfAD
75-7 70.100 :`.?ON r : V
LA Q11WITA CA 97253
PALIM, DEZZlIff CA 921260
3221
USE OF PERMIT
1"_HT,DE 1%kT,.,:E MOi$1r1..,
KITCHEN REMODEL, PPIfi APP R.C31 F41 PLANS.
€11.9. lR:KMODEL 18,000,00 L3
PLAN CHECK RZ 101. -000-•._'3, X -318 v vx
C-014STR.iTCY'ION r9Z 101-000-418.000 $199.06
'
MECHA141CAL f+KF 101r000-421-000 X1+3.80
1?L9CTKZJ' .t#L VEX 1,01-0f,I0-4,20-000 14;.40.00
'Fi.•mS131ma. 101.000-419.000 $2j,00
;°FRO'ldt:43"df0TlON'FEE,-R'fSIID 101 -0004AI-000
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I K-414.[5
CITE( OF LA QUINTA
FINA CE DEPT.
RECEIPT
DATE
�. ' 7
BY
j
DATE FINAL�p
G/p
INSPE O
ar/
L61
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 DeckExhaust
f:7-
Fans
O.K. to Wrap
F.A.U.
Framing
d - - vY
_
Compressor
Insulation
f/J- 1 z -
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 _ - - 7�
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
Ej
Encapsulation
Gas Piping
//
Gas Test
Appliances
7
Final
Final /� C��
Utility Notice (Gas) ! 2—
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 y
Utility Notice (Perm)
COMMENTS:
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V City of La Quinta
Building 8t SafetY Division
P.O. Box 1504, 78-495 Calle Tampico .
La Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
- Owner's Name:
Permit
Project Address:
A. P. Number:
Address: jF8 1 10 S
Legal Description:
City. ST. Zip: _t
ZAc
Contractor: -
Address: ,' `Z
City. ST. Zip: ZZ
Telephone: / —3 Q
Project Description:-
Telephone
l7:,*
i J70�.J o
State Lic. # itv Lic. #:
.
Arch., Engr.. Designer:
P/ASS a xx
r YJ= L Liri2
Address:
City. ST, Zip:a
3 I c e?� 1
Telephone:
StX.ate to Lic. #:
Name of Contact Person: f 1 ce-s
Construction Ctl
on Tv e. �•
_ a
Occupancy:
P nc•
Project ect t_N Pe (circle one):
� Add'n Alter Repair Demo
Sq. Ft.: )�Wml Stories: # Units:
Telephone # of Contact Person: ,O sz—D
Estimated Value of Project:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FEES
Plan Sets
Plan Check.submitted/
Item
amount
Structural Calcs.
Reviewed. ready for corrections
9
Plan Check Deposit
Truss Calcs.
Called Contact Person
Plan Check Balance i
Title 24 Cales.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
!/ OZ
Mechanical
GFading plan
2nd Review. ready for correctionissue
�t1
Electrical �
�p
Subcontactor List
Called Contact Person
W
Plumbing
2r,fla
Grant Deed
picked up
SALLH.O.A.
Approval
��
[Plans
lans resubmitted
Grading
IN HOUSE:-
"' Review, ready for corrections/issue
Developer Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue ,e
101151z
School Fees
F_
- I
Total Permit Fees
ARCHITECTURAL
NAME(S)_�'j- oc ;:
STREET ADDRESS
04-09-02P02:28 RCvn
EXHIBIT "1"
IMPROVEMENT APPLICATION AND AGREEMENT
DATE_ _I : C `�
A r.7
LOCAL PHONE77I¢D 1 OTHER PHONE o -
2 7�3
REQUESTED IMPROVEMENT ,
!L 1- Ac4c,
------------
Approval is requested for the above improvement accor
tion
the plans attached. We have attached two ding to Plans
outlining the work to be done along with a completetdesof
cripans
of the, materials and colors to be used. If we a
re
contractor(s), we enclose copies of the Contractor's Licen el ng a
Attachments:
(1) Two copies of the Architectural Improvement Application.
(2) Two sets of plans withmaterials and colors to be used.
Note: ' One set is for the management office; the of
set to be returned to you as "Approved". her
(3) Contractor's name and copy of contracto '
equired if the improvement is under r s license. (Not
"Owner -Builder"). $300..00 or if
(4) Brochures (2) and/or color samples of manufactured products
to be used. P is
We have read the Architectural Committee Rules a
and have furnished copies to all contractors to be engagedby
us and we agree. to comply with those Rules and Guidelines•
We also understand that it is our responsibility to insure
our Con�tractor(s) comply with said Rules. that
Building"' P•°emits for home; improvements may W e are required acknowledge that
City of La' Quinta. The cost bf y q y the
obtainingPermits, responsibility for
them, and the subsequent inspections will be our
responsibility. In all cases we recognize the requirement to
be in compliance with applicable building codes including, -but
not limited to, those adopted subsequent to the original
completion and acceptance of our dwelling.
Rev. 4-96
OVER
ARCHITECTURAL COMMITTEE CERTIFICATE
(Exhibit "A" to the Architectural
Improvement Application and Agreement)
The Architectural Improvement Application3'and g e --bent was
reviewed by the Architectural Committee on Gi 6 a`and has
been:
c/.. Re • • - -
Approved_ Conditionally Approved 3 ected
subject to the following
conditions set forth below
Returned for Further Information
Required Modifications
Comments
Yes No
Recording, to be' sent by 'owner., to County .Recorder's
office for roof and/or exterior: wall modifications.
Deposit Required Deposit'Amount d
Date Arc itectural Com6ittee
Architectural Committee Architectural Committee
Architectural Committee Architectural Committee
NOTE: THIS APPROVAL IS VALID FOR 90 DAYS FROM APPROVAL•DATE
Rev. 4-96 ti