9510-072 (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 II force and effect. G7��SiJii s /
License #, V =' �" Lic. Class <-` 61 Exp: Date (C' ! i
Date i171Zc; 3 Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm 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
performpme of the work for which this permit is issued.
(VA 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?Wdirkers' c mpensation insurance carrier & policy no. are:
Carrier 5 '}""' °�` "`� 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 be 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 1130 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 represebtatives of this City to enter upon the
,above-mentioned property fo rection purposes.
Iri
/'Signature (Owner/Agent) Data
A"'
'—.BUILDING PERMIT
PERM'T,s'"
DATE
VALUATION "+`P"'"'' y LOT
TRACT '
JOB SITE ADDRESS 79416 S C:i URT
APN —
OWNER
CONTRACTOR
ATLAS AW1Qt) O
ItA'. GRAN.VI ..1
751 .s.';L,I.` AMS
79410 IRIS COURT
PtII..It'i: SP1iIIrjC S Chi 92262
LA. QUINTA CA 92253
6193278467 CBL#
DESIGNEWENGINEER
USE OFPERMITAKi
(2)1C801',A.T10 COVERS (1) 4708Y., AM) (1) 455 S,,F.
M REAS. YARD S13`1BACK ADJUSSMWNT APPROVM PM ib3 -91"M
FEE DESCRIPTION
FEES
PORCH/PA' 0 925.()6 Sr
IEIST,MA 1 ED COST OF t,_GN3Tj71tU t ION
.2,30MO
�
9 S
SULI 'C3 i'AL CONIST'R.UC 'IJ.N skI>.t7.'1.,i1N CI`3.I CK
$2890
LESS PRI: -PAID n"E'S
$0.00
TOTAL PE'L.�!'.[fVFEES �)VE HOS NNT
$238.90
[
j Okms PROJECT PERMIT FEES
. .90
.38
RECEIPT
DATE
BY
DATE MAILED
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
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wali Insulation
Condensate Lines
Party Wail 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 I 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)
COMME
/
Q
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� �w4�rHrw
MEMORANDUM
CASE: GJS FS: > Location(s) : �%- 1710
Request(s):
` r1
Your setback adjustment application is hereby approved., subject to
the following conditions:
Conditions: ,
1. Obtain a building permit from the Building and Safety
Department.
2.1 The other Zoning Code provisions shall be met.
3. If ground excavation is required, please contact Underground
Service*Alert (USA) at 1-800-.422-4133. The service is free of
charge provided USA is given at least two working days'
notice.
4. Additional Conditions:
After review -it was determined that:
1. This adjustment is consistent with the intent and purpose of
the Zoning Ordinance.
2. There are special circumstances applicable to the property,
including such factors as size, shape, topography, location or
surroundings that justify approval of the adjustment. These
.circumstances are: _ CA
Thao�fo your cooperation.
/G.
c: Building and Safety Department
�.; CASE NO:
CITY OF LA QUINTA�; ` %j FEE: $100..00
PLANNING & DEVELOPMENT.DEPARTMENT
) ,
APPLICATION FOR SETBACK ADJUSTMENT .','
APPLICANT: Submit this form with two copies of` --a sdaled site plan,
drawn to adequately depict the nature of the request. /A nonrefundable
fee of $100 is required when the Application is submitted. Check must be
make payable to the "City of La�Quinta".
If the Applicant is not the owner of the property, a letter must be
submitted by the owner authorizing the Applicant to execute this document
in his behalf.
PLEASE PRINT OR TYPE
APPLICANT/ CONTRACTOR: OCAC, A
CONTACT PERSON ( I F DIFFERENT) CA0 `r'v
MAILING ADDRESS: Sc
(Address) I (City)
OWNER'S NAME: CV-D\V\ V , `) I P � , 1�,\, V
MAILING ,ADDRESS: 79 _7 (0 J\^"S C 1. L,,,- k�,�
ress) (City)
STREET ADDRESS OF PROPERTY: --
LEGAL DESCRIPTION OF PROPERTY: LOT #
ASSESSOR'S PARCEL NUMBER:
ADjJUS'
l�
REQUES
0
V_
�cP V
(State) (zip
TRACT
REASON FOR REQUE
c
t
JUSTIFICATION: No request for a Setback Adjustment shall be granted
unless it is determined that it is consistent with the intend and purpose
of this Ordinance; that there are special circumstances applicable to the
property, including such factors as size, shape, topography, location or
surroundings that justify the approval of the adjustment of the setback
,requirement, and that the adjustment will not be detrimental to the
health, safety, and general welfare of the community or be detrimental to
property in the area of the parcel for which the adjustment is requested.
FORM.013/CS
DATE
C941'__
PHONE
(State) (zip)
PHONE
Ki .
(State) (zip
TRACT
REASON FOR REQUE
c
t
JUSTIFICATION: No request for a Setback Adjustment shall be granted
unless it is determined that it is consistent with the intend and purpose
of this Ordinance; that there are special circumstances applicable to the
property, including such factors as size, shape, topography, location or
surroundings that justify the approval of the adjustment of the setback
,requirement, and that the adjustment will not be detrimental to the
health, safety, and general welfare of the community or be detrimental to
property in the area of the parcel for which the adjustment is requested.
FORM.013/CS
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ATLAS AWNING COMPANY '
Calif. Contractor's License No. 376238
754 Williams Rd. (619) 327-8466
PALM SPRINGS, CA 92264
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NOTES:
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