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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
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
corr�pensation, 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 rAeas n
Date Signature of Ownerii1
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 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 M. I f K
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 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 authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) I `�t� •� Date
BUILDING PERMIT PERMIT# O
DATE 4%4W VALUATION LOT
LOTJOB TRACT
ADDRESS
APN
OWNER
CONTRACTOR / DESIGNER / EN (NEER
GARY ivjONT'k�..I...M40,
RI
7s 9.733;'..yfi'b UP 4DRIVS
L :gutN tk CIA �_M s
3 OSLO
USE OF PERMIT
t.v '�'FAJ! CJ' Ylydi R. , .l.seJ •:.,i,L'A.. r .�..:tE.. 6ah.lc'.3 !'; C�i.i'. '� i� .
C:O)zjMTRU ;'IOH FES: 17 i •{,*0-418.000
Zi,KC I'RICAL H'LT:: l fdi • !t)•d• ? f y0 i n .,
S1RV'NOMOTION FE49- rUCSID 101.000.241-%0 +::a
D �� D
AIR 0 4 2003
CITY OF LA QUINTA
FINANCE DEPT.
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RECEIPT
DATEBY
I./ � `"1
5' ill
DATEFINAL��
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 Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final '-t (9 t
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)
No> y -)A-. dc . b>g
D F �� mss oN
6.e4kllaf *
Bin #
City of La Quinta i
Building 8t Safety Division .
P.O. Box 1504, 78-495 Calle Tampico
Quinta, CA 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Permit #la
QtfXo ' b
Project Address: `
Owmer's Name: L U
A. P. Number:
Address: * - 3 PYAJ L t L,
Legal Description: Pprnt ��\ D �U c.C' S ti L�
City, ST, Zip: CD U tN-vt , C{
Contractor: -)t 7, A,
Address:`l
Telephone:
Project Description:
City. ST, Zip:
Lit, -
e:
Telephone: _1�
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State Lic. # : City Lic. #: rj��
Arch., Engr., Designer:
7
k v -'M o t -u o a- Qv kbvt�- 4' Cl 0C
Address:
City, ST. Zip:
Telephone:
P
State Lic. #:
Name of Contact Person: �(� rn O�1
u
Construction Type: Occupancy.
v .P
Project Type (circle one): New Add'n Alter Repair Demo
Sq. Ft.: Z # Stories: # Units:
Telephone # of Contact Person:
Estimated Value of Proiect:
APPLICANT: DO NOT WRITE BELOW THIS LINE
#
Submittal
Req'd
Rec'd
TRACKING
PERMIT FJEES
aPlan
Sets
Plan Check submitted
Sz
Item
Amount
Structural Calcs.
Reviewed, ready for corrections
(phQ
Plan Check Deposit
Truss Cates.
Called Contact Person
b (�
Plan Check Balance •
Title 24 Cates.
Plans picked up 0
t�M
Construction 0
Flood plain plan
Plans resubmitted
**Icchanical M%A� VAW
Grading plan
21' Review, ready for corrections/issue
Electric(8x.-IS)v
Subcontactor List
Called Contact Person
Plumbing
Grant Deed
Plans picked up
SAI.1.
H.O.A. Approval
Plans 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
School Fees
Total Permit Fees
3 15103 *�O
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CITY OF LA Q UINTA Case No.
0 Community Development Department Fee: $200
U -
F APPLICATION FOR MINOR ADJUSTMENT
APPLICANT: Submit this form with two copies of a scaled site plan, drawn to adequately depict the nature of the request.
A nonrefundable fee of $200 is required when the Application is submitted. The check must be made payable to the "City
of La Quinta". A Minor Adjustment Permit (Section 9.210:040/Zoning Ordinance) may be approved only for deviations
of up to ten percent of a numerical development standard (for example, a reduction of one foot from a ten -foot setback
requirement) or for deviations specifically identified in the La Quinta Zoning Ordinance. Other deviations shall require
consideration of a variance (pursuant to Section 9.210.030Nariance\Zoning Ordinance). 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
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APPLICANT/CONTRACTOR: U R V( IC . M vN7 ULi.Wb DATE: b -1 S - p z
CONTACT PERSON (IF DIFFERENT):
PHONE:
MAILING ADDRESS: r1-� �% DC�N��Llrn� 7��?,>> 1.� ���t1J1J'i�l �`�1 • �1��s3
(Address) (City) (State) (Zip)
OWNER'SNAME: 1L AfuTy' 1 t Il
MAILINGADDRESS:-1c1-�l �� t� 0L l (xy (Jif, LP- Cdu�o,-tiA c --L, G 2 -?—S-
J
(Address) .(City) (State) (Zip)
STREET ADDRESS OF PROPERTY: -1 Ci -1 7S--1'-1.1 ®)P�rrnou cty 1ilZ- LA A L—A 92-LS_�
LEGAL DESCRIPTION OF PROPERTY: LOT # TRACT c� 5 �D 9 1
ASSESSOR'S PARCEL NUMBER:
ADJUSTMENT REQUESTED:
C� c_-( N1\30 v bn,� V- t _ 2 tS15`Tk ut. [.L)5) Pi,,LA St ,�A� e�n� D GcSrt
REASON FOR REQUEST: o L � \> L�A w 17 1-1 l -N -r 1--i L- r9 n e- ` , L� t
L- u � c L c, L. b A-' C', -�
SIGNATURE OF APPLICANT DATE n a --
SIGNATURE OF OWNER (if not the same as applicant)
PLANNER:
The following findings shall be made by the decision-making authority prior to the approval of any Minor Adjustment
Permit.
1. Consistency with General Plan. The project is consistent with the General Plan,
2. Consistency with Zoning Code. The project is consistent with the provisions of the Zoning Code.
3. Compliance with CEQA. Processing and approval of the permit application are in compliance with the requirements
of the California Environmental Quality Act.
4. Surrounding Uses. Approval of the application will not create conditions materially detrimental to the public health,
safety and general welfare or injurious to or incompatible with other properties or land uses in the vicinity.
e 7\F -n 11
GARY K. MONTELLANO
79-733 DANDELION DRIVE
LA QUINTA, CA. 92253
760-772-0553
January 17, 2003
City Of La Quinta
P.O. Box 1504
78-495 Calle Tampico
La Quinta, Ca. 92253
Attn: Building & Code Compliance -Butler
I Gary Montellano would like to ask for an extension on my garage conversion compliance, to
be up to code so that I can get proper permits to comply with the city of La Quinta. I would like
to ask for the date of March 15,2003 if possible. We applied May 29, 2002 for address located at:
79-733 Dandelion Dr., La Quints, Ca. 92253. I've had some trouble retaining the services of an
architect, it being such a small project. Everyone seemed to be so busy, but I did talk to one that
told me that he should be able to get something drawn up in the next 4 to 6 weeks. If this works
with you I will go with him. This should fit in the time frame that I am asking for.
I appreciate if you can work with me. You can reach me at my office from 9:00 am until 4:00
pm Monday through Friday's at 36070899 or 342-7660. My cell#27573885.
i
Sincerely,
Gary K. Montellano
CITY OF LA QUINTA
BUILDING & SAFETY DEPT.
APPROVED
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