0208-036 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby -affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Seof Division 3 of the Business and
Professionals Code, and my License is*n full force and effect.
License # Lic. Class Exp. Date
65 1' C,5a M9 Cry 1(1 ,,/2(
� r
Date �� Signature of Contractor rr, 1
}.
OWNER -BUILDER DECLARATION
I hereby affirm under.,.penalty of perjury that I am exempt from the3Contractor'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.
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 g'1".s Tg CCsMT'gNaAyf Policy No. PA6000610_01
(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, (shall forthwith comply with 3ho£eRprovis4t
=Date: - Applicants
v t�
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1
. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for irj$pection purposes.
Signature (Owner/Agent) Y11 t ` - 1 Date l`' I
BUILDING PERMIT MERMIT#
DATE VALUATION LOTS TRACT
9 - - o _Z_
JOB SITE
ADDRESS %91-W-5 eD. UVHL ' +�i' A(RX D:%TV .
APN
OWNER
CONTRACTOR /DESIGNER / EN INEER
79-•945 DOUBLE, EAGM, Ta.R
74725 30AIDWE, BUM,- #A
LA Q= 11 -A -A (:A 914,253
F?ALNI DOSM CA 922,60
(7!60)340-9000 CUA 00355
USE OF PERMIT
P(. 01 41:(71C)R h -A
PCIOUSPA/BB(Z .AL.A-RMS{B.tiRRIPME, SHAtit, BE IN PLACe PRIOR TO
:E'RC`-PLF STt~.�'..iNf3Pd?�C' ION'
PO L,AidWITZ.. 81% 2.7,00.00 U
ESTIMATED CMT OIF C°CaMMUC1"TON 2210W.00
.1'f,'1: •4 rv��.l+.11 -�LYa 19 C�.lY;YivdFti YWS
PLAN ("H Cg. FE7, 101-000-439-3146 3146.25:
CCaN. i'PI.t'Erw'liON M 10'1-000-419-000 $225.00
MECHA'1ti1s<".. , FEE •- POOL 101.000421-'0N $2�.06
.iPL "1'.R1CAL PE'L: — l O,O.L, 101.000.420^ 000 $45.00
PLUMS INO."IF,. — Pool 101.000-419.000 =00,
MD PLANTIM CK S40.25
MR S $Ms DUE .rrOW
�,au�aTa
OV
ANCEpEP'T
RECEIPT
DATE
'
BY:
=
DA Ir�AL
SPECTOR '
W.
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
jn,sulation
Vents
> it emplace P. L.
Grills
;ire place T.O.
Fans & Controls
Pa 4y 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
Gas Test¢j
PLUMBING APPROVALS
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)
aQ uc aeverizi-A Clausen
July 25; 2002,
Mr. Don Clausen
14505 Bowdcn Court
Morgan Hip, CA 95037
Reference:
Dear Mr. Clausen:
PGA WEST Il RESIDEV'TIAL ASSOCIATION, INC.
PO. BOY 12S', LA QUINTA, CA 9-2-253
(760) 776-5100 FAX (760) 776-5111
79-935 Double Eagle Way. La Quints. CA
Architectural Change Bequest — Pool, Spa and Patio Decking Extension
The Architectural Committee received and reviewed your revised plans for the addition of a pool, spa and
patio decking extension and approved your application, with the following comments:
• A letter was received from The Club at PGA West on your behalf approving an encroachment of
the pool improvements within the setback area.
• The 30" wail was removed from the drawing.
• Please be reminded that if the fire pit is gas fired, it must be in accordance with the City of La
Quinta code requircutents and be permitted by the City.
Review by the Committee is only for general conformance with the architectural guidelines. It is the
responsibility of the owner to fully understand and conform to the architectural guidelincs criteria whether
or not all deficiencies are noted during review. It is also the owner's full responsibility to field verify all
existing conditions. The Comnuttce's decision with regard to project design will be final Please refer to
the Architectural Rules for all required submittals.
There were no landscape plans attached to your application 'therefore, additional landscaping was not
considered and is not part of this approval.
Pleasc contact Javier Contreras, supervisor for Valley Gardening Service at 760/776-6667 and Carol Fuller,
the Association Manager, prig to any irrigation modifications associated with this change. Damage to the
landscaping, i.e., shrubs. trees, flowers and turf is he responsibility of the contractor. Tile landscaping
must be brought back to its original condition when the project is completed.
Approvals given by the Architectural Committee are good for only six months from the date on he
approval letter. After that time a new application must be submitted.
Upon compietion of your project please complete and return The Notice of Completion of Architectural
Change.
uu� co uc lii:tia beverl�j A Clausen
406 776-9525. p.?
Mr. Don Clausen .
July 25, 2002
Page Two
In the meantime if You have any additional questions or concerns, please do not hesitate to c
Fuller; Association Manager, at 760!776-5100, Ext. 20. ontact Carol
Su' =rely,
PGA WEST 11 RESIDENTIAL ASSOCIATION
For the Architectural Committee
For the Landscape Committee
Carol Fuller, CCAM
Association Manager
cc: Board of Directors
Unit File
119