0310-105 (RPL)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 # Lic. Class Exp. Date
".. 8 G`J3 Thi~ lW."o
rt3 ifx
�tf SA." JlVin/✓ !♦
Date 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, 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 a Qrm 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 ofihe work for which this permit is issued. r
)„I have and will maintain workers' compensation insurance, as required.,by
Section 3700 of the .Labor Code, for the performance of the work for whid this
permit is issued. My workers' compensation insurance carrier & policy. no. are:
Carrier hWh C:+:?1A#EIVA,T% Policy No. it k 4tk;�±f-�f1t1
(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' compensatio oo-Ovisions of Section .370 of the, Labor
Code, I s all forthwith comply with those/provisions. r �.
Date: ” Y`% r"� Applicant N7 ✓/. fi'
Warning: Failure to secure Workers' Compensationcoverage 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'Safe'ty
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 .6f 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,4'iepresentatives of this City to enter upon
the above-mentioned property for inspection purposes
Signature (Owner/Agent) l^«��Date'
PERMIT #
BUILDING PERMIT�,..�;
DATE VALUATION LOT TRACT
ADDRESS 5 441 LArA I':.ii'u\.,/��.�:P��ot�, JOB
APN
OWN7E�IRY�
CONTRACTOR DESIGNER /EN61NEER
cYrt3tlW, d',lILS & Mta(7yup mfco
V-641 MEJUA-C111
611TFSUA-CMA
'16-1(3sVi C 5 ,
LAypmITA 0% 92 2153
tihAMMULlA (1," :2 236
(760)398-9222 :v'1'I g 0031515
USE OF PERMIT
F001..iai•FWOR
ce Lis r.��,, stx, ri;..;.,nr.�.�.z�M.r.�aa�trr►,r�a�r,t•��"t��a�,
5 LJ, 9 tia°iCK W.&U, CITY STAwDA RD.
a 9LA",rX- Q_.Ar- X'.1Pwt',' ` .tIALL UE IIN PLACE .AT VRY,,PLASTI;R IWSPZC'1701ii +
S.00 LP
i�«C)i..��L°+Fr12;�A& Ids la'.Go 1...1111
PLAN -CHE.KM101.000.439--318 91w AV.
MECH,&MAK,,PO-OL 101•000_4�1110013 $24,00
ED.C'C1Zlr_i�L FL`Z ..,- POOL 101-00"20-000945.60.
P1:.tFI~ DINr.4URE'–PON, . 0'ON$
�V L:+",L'(}7.1�dr 4 `➢��a3.ii�iJ�.��'V8`F A�:i YAF �"�.+C'fN '{..i'.�,��•ss,.�.4'tP
y�i�l b.�
Masi
IT 3z IU7 NOW
S45249
NOV 1. � 2003
CITY.OF-.LAQUfNTA . .
RECEIPT
D'ATE'�!
�j' ' i �✓
BY' �, f
E FIN
INS
TOR
Al
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
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
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: '-
RVA
17 1
—�— ,r
November 12. 2003
Mr. Henry Bullock
490 South California Ave., 0' Floor
Palo Alto. CA 94306
PGS, WEST II RESIDENTIAL ASSOCIATION, INC.
P.U, BOX 1282, LA QUiNTA, CA 92253
1760) 776-5100 FAX (760) 775-5111
Rcfcrcncc: 57-641 Interlacben. La Quinta. CA 92253
Architectural Change Request - Pool, spa. water k. a- barbecue and
additional landscaping .
Dear Mr. Bullock:
T'hc Arehiteet,xral Cornmiuce and Landscape C"01nmiuec respectively m iewed and approvod yotrr rcvised
plans to add a pool. spa, water feature. barbecue and additional IAntseSping.
Review by the Committee is only for general canfonma= with the architectural guidelines, ft is the
responsibility of the owner to full
y understand and conform to it= archiloctural guidelines crlteri�7 whether
or not all dd-iciencies Arc noted during review. it is also the ownix's full resPonsibilby to field verif - all
existing conditions. The Committee's dedslon with regard to projxt design will be final. Ploase refer to
the Architectural Ru)cs for all regtrired submittals.
Approvals given by the Architectural Committee arc 9006 for only six months .hm Clic date on the
approval letter, lfconstruction has not commenced within six months after the pmjoet Approval date, a nem,
application ttlttst be submitted.
The Architectural Committee TIAs VII follov► ing comments:
• PWsc make stue the tiki torclics are ren"ovable.
• Added lighting should match cxisting and be connected to homeowner power,
• Refercnce page 2 of, 20 of the Architectural Pttics and ApplicAtion for Change. wlucli
states, . , ."11111ass othemr se determined by the Board, buil,-jg yetb(7cks at PGA WEST 11 arc 20
fart from p oper►v litre in front, 15 feet jrv,ar property line 07 �gD�f GO11r6@ ,ride for additrorts (roof
overhangs may 1701 eircroach into the rear zelbackv), 5, feet,, nvnr pmperty line on golf
coarse sicfe for pools. spas, water faratures, hardseape, near malls, etc., arr<>'s feet frnmi .ride
property lure,.... - The commiltoc agreed to allow a 2' sefb�ick from the common wall: 111crerore
please sign th4 enclosed indMurtificatlon acid renutr to The 14onarch Group for recording.
The landscape Committee has die following comments:
• . Your contractor must warrantor the trees fbr one year and Oir.0rubs fbr six months,
• Additional annual color planted as a result of this submittal will not be replaced by llic
Association.
• Added shrub and turf irrigation should be on separate conkrcls due to o",er-seeding in the fall.
PIC= contAct Javier Contrera& supervisor for Valley Gardening & :-Vdscape at 760/776-6667 and Carol
Fuller. the Association Manager, prior to any irription modification,, associated with this chatlgc. Damage
to the landscaping i.e., shrubs, trees. tlMom and turf is the responsibility of the contractor. The
Wndscaping must be brought back to its original condition when, the Froject is completed.
Mr. Henry Bullock
November 12, 2003
Pa$c Two '
y Upon completion of your project. please complete and return The Notice of Completion of Arc11iiach.>ral
Chanpec so d1at your performance deposit may be returned,
If You have any questions, please:do not hesitate to contact Carol Fuller, Amsuciation Manager' an 7GU/776..
` 5100, EXt, 20, or Cathy Clark, AssistA nt Manager. Ext. 18,
Sincerely.
PGA WEST 11 RESIDENTIAL ASSOOATTON
For the Architectural Coeunivee
For the Landscape Carotndttee
Carol Fullcr, CLAM
Association Manager
Enclosure
cc: Board of Directors
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