0305-302 (PAT)LICENSED CONTRACTOR DECLARATION
__l 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
26,046413.0 �)C/? �. .11/2(
Date L t.r•Signature of Contractor
OWNER -BUILDER DECLAF31TION
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.
( ) 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 STATS FUND Policy No. 2204451IS-1EA
(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' compensatioeprowsior of Section �310 of the Labor
Code, I, shall forthwith comply with provisions,.,
ions.,
Date: Applicant I A/ t
00,
Warning: Failure to secure Workers' Comp nsation coverage is unlawful and
shall subject an employer to criminalpenal✓iefs and civil fines up to $100,000,. in
addition to the cost of compensation, d'a'mages 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 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 wit-1all,C'if-; and�State laws relatiggj. the building
.construction, and hereby authorize representatives of thisCity to enter upon
the above-mentioned property for inspection purposeF)
,Signature (Owner/Agent) ` ��'� ----Dat `5 i 1 4,010 �
-�' PERMIT#
BuW NG.PERMIT
DATE05" VALUATION $1 A48.70LOT . TRACT
JOB SITEA��p
ADDRESS «i - n VZs�,+tLv�.I�TdW
APN
}
OWNER
'CONTRACTOR/DESIGNER/EN INEER
TOIL .BU TAE4:4MZ ` . t
P lxrm OumlavCTlt'3Af
48-555 WA AMUSTAD
74691 �SWE :i W1.'U, 90AD
I.A QUMA CJS 92253
TRCYUHAN-D PALM CA 92276
(760)275-6017 CiS'� 3100
USE OF PERMIT
PAM
139 S.lr, A1,UMAI? OOY)•L A7' 1C;1r RAtro CGVKR, PlKR.,AFY'l 0V9J3 PLANS •
P'ORC.HIPATIO 139,00 OF
; COST.OF (,'0. &TR13E'�'10N'
1,644.0 .
('!'(�/ '�Eh��f:e"'MATED
y� FEE
FERw1 i'9EE f�l1iY. �BY:.�$
PI.tAN CHECK FEE 101-000-439-318 $27.93
CONSTRUCTiOP Mt 101'-004-418-000 $43.00
SSR -0110 MO 1'101 FER - MID 101-000-241.000 2.50
MAY 3 p 213
CITY OF LA QU14TA
FINANCE DEPT.
M3340.EA L COlttiiSA22.1J'M09 a4N.i2.191',.AW CHECK
?�.'1 6 TEES
$0,00
TOXAL FF.M rk -S. 1) UE 1f0W
$71.45
RECEIPT
DATE'
BY
DATE FINA D
INSPECT
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 AM
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans E Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
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
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Dough 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:
+:-01-03 A02:19 ill
f
EXHIBIT "1"
ARCHITECTURAL IMPROVEMENT APPLICATION AND AG EME
DATE y O�
NAME( S) Gl ��G2
('Pri t)
STREET'ADDRESS
LOCAL PHONE, -OTHER PHONE
REQUESTED IMPROVEMENT /?Z6/%A ®., A4ie,, llAetIIl-t
r _
��rAeW
M C- 4/T:5
Approval is requested for the above improvement according to
the plans attached. ,,,We, have attached two (2) sets of plans
outlining the work to 'be done along with a complete description
of the materials and colors to be used.If we are using a
c_ontractor(s), we enclose copies of the Contractor's License.
Attachments: .
(1`) Two copies of the Architectural Improvement Application.
(2) Two sets of plans with materials and colors to be used.
Note: One set is for the management. office; the other
set to be returned to you as "Approved".
(3) Contractor's name and copy of contractor's -license. (Not
required if the improvement' is under $300..00 or. if
"Owner -Builder").
(4) Brochures..(2) andtor color samples of manufactured products
to be -used.
We have read the Architectural Committee Rules and Guidelines
and have furnished copies to all contractors to be engaged by
us and we agree to comply with those Rules and Guidelines.
We also understand that it is our responsibility to insure that
our Contractor(s) comply with said Rules. We acknowledge that
Building Permits for home improvements may be required by the
City of La. Quinta. 'The cost of permits, responsibility for
obtaining 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 ou'r dwelling.
.OVER
Rev. 4-96
P
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