0212-139 (MISC)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
'774582 B 033 Bic
Date*/ L 1P 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).
( ) - 1, 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
11 - 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.
(7) I have and will maintain workers' compensation insurance, as required by
Sdction 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 8? ATECXi O Policy No. 458'i'k
(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 proyisions,of-Section 3700 of the Labor
Code, I shall forthwith comply with those provisionse
Date: 2 L ti.°–,r ,; Applicant—
Warning:
pplicant Warning: Failure to secure Work6re'Compensation coverag/kUnlawful 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 tci enter upon
the above-mentioned property fog nspection purposes
Signature (Owner/Agent)
BUILDING PERMIT PERMIT#
DATE �� VALUATION LOTS" TRACT
I .0n..d�f; 4, lf�Jdl iD
JOB SITE
ADDRESS%�ti�t�.FF�:T�'�A' 5.5-35.3
APN
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OWNER
CONTRACTOR / DESIGNER / EN &NEER
I3GAVMT REM NTML 110A
woclf wC.
4Z-61,11 CAR LME, COURT
70.56 C ONVIDY C;+.KnIa
PAi:.M,:t'7nMZ CIA 92211
S"All M4,0 ? Cts,. 92111
(858)560-0698 r_214
USE OF PERMIT
BLM 6:SS-�42;'3�3 5-365. RX-PAIR.fr`P.-N tS:AI1 5 &Uf? X
COA,TTRO
VALUATION ug
- w0.YS.AyY8+S9•, L ) con or. cota,0.R5,mno39
44:hA00
MW SMWARY
00N3` R1JCT*N FY -9 101-000-418-000 S30100
ff?A�1.�+1'JyyD,Pvay4���.,qq�s��������'ss�t@;�yy:.�Cii°,�IC
$30.010
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•«frifSei eS_ !Li NOW
%7'30.00
t:
RECEIPT
DATE/,,/
BY F'
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
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:
Send to:-
EPOCH CONSTRUCTION
Address:
Attention:
HARRY
i 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 Hills and.Laurel Valley. We find the repairs to be
in conformance with the manufacturer's specification and are
approved by our office.
OIL
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 AVENUE SAN DIEGO CA 92101 VOICE:.619.231.9?D5 FAX: 619.231.4288
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