0212-137 (BLDG) Building 4LICENSED 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
4`13.3 111G, 0W.Mc
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 OV6Perty, 8R1 excluslvely uurllrai,tiny vvilh liacn3cd
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 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 ST,,T , Policy No. 46"94
(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,`provisiorfs.
Date: 'f l�l-�' 6J;hpplicant
Warning: Failure to secure Workers''C pensation 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 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 author representatives of this City to enter
the above-mentioned property for inspection purposes.
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Signature (Owner/Agent) `l -;' "" —�� { Dates"r'=
BUILDING PERMIT PERMIT# :
DATE < U VALUATION LOT TRACT
JOB SITE
ADDRESSr�wi3,uj���
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
42-640 MOLNE P!01IRT
7061 CONVOY €;OURI°
PALM 1."y1 SERI 01A, 92211
S AN D2,01 CA 9 111
USE OF PERMIT
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iTA14U,ATIO14 1.14
+TUMIED 'COTST 013' CONSMUMON
4,1500.00
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CONS` RUC,`•9i A'a2V PEE 101 -ow -418.0,00 $30,00
TP 03MUM-1014 AND KAW _T,
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RECEIPT
DATE Jj,
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
0. 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
POOLS - SPAS
BLOCKWALL APPROVALS
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
COMMENTS:
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)
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Send to:
EPOCH CONSTRUCTION
Address:
1.
Attention:
HARRY
Regarding:
PGA WEST 2 - MEDALIST DECK REPAIRS
. From:
Date::
Tim Golba
Copies To:.
1 /28/03
File
Comments:
Harry,
Please let this memorandum confirm that our office has inspected all
14 buildings of deck repairs for the current MEDALIST phase of repairs
.
for PGA West 2 Residential Association. This includes all of the upper
level entry and rear balcony deck repairs for the buildings along
Winged Foot, Southern Hillsand Laurel Valley. We -ind the repairs to be
in conformance with the manufacturers specificallion and are
approved by our office. .
Please let me know if we can offer any further clarification for you or
the City, of La Quinta in this matter._
Sincerely.
Tim Golba, Principal
GOLBA ARCHITECTURE
G O L 8 A A R C H I T E C T' U R E
656 NINTH,AVF.NUE. .SAN DIEGO CA 92101 VOICE: 619.231.4905 FA,X: 619,231.42.88'