9511-131 (RPL)LICENSED CONTRACTOR DECLARATION
I hereby affirm 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 as ('y'Exp. Date
Date it, Vic, Signatureof Contractor a//
OWNER -BUILDER DECLARATION
I hereby affirm 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).
O 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.
( ) I Have and will maintain workers' compensation insuranbe, 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,
1 shall nop%y Vvf 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 pr visions.
Dater .; rI.-.4!j Applicant
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, -Pr pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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
A01T.-mentioned property for inspection purposes.
Signature (Owner/Agek) Date
ALC "BUILDING
PERMIT
PERMITS.511 I;I
DATE
VALUATION $112,499.7! LOT
TRACT
JOB SITE ADDRESS
APN
S 260 AVENIDA VILLA
771-7474.-004
OWNER
CONTRACTOR Y
V 0,,' N POOLS
1? fl9r..T�1n t� !'17 0• P" I ft Cr}"{y
1i:0.Vlf.t"11'atJ YY �.:�r. 1:eyA tit .1 ,[Tt'�,i... i.�.
`1'TS A'F A j�jC Q'Y'
-^.'.J.J I.J 1i71:iYL1 ItU�'1 LJA
32,260'AMi IDA VILLA
1ND10 CA. 92202
J,A Q'GJIN'TA CA 9.22.53
(7: L31. 1151
DESIGNERIENGINEER
USEOF,PERMI,)WL ANIVOR. SPA
PO(X, ONLY -1410 HEATER EXIST INO 3' 11iGH WALL TO B 13.�i..01ASHED AND KEPLACIM
ION
WITH 74' OF S' IfiJGH GARDEN BLOCK WALL. 'Y FRONT ?fA1+D SETBACK REDUCTION
Oyl:,IJ K VA` XC --
DESCRIPTION
FEES
POOL AMOR, SPA, 10;$7c.ttE1 LS
S F`1'. WALL 75.00 Li:
1'�$YMAI Efli COVC OF CONI S -11"'R tCRON
IZ 499.75
VERMITFEL SUMMARY
PLAN C14RCK Fly 101-000439.3..19 3f3t.S�5
CONSTRUMIOiv F 1.OI-fat)-�t11i-p0U $1 sd.1i0.
MIX.'14AN1CAL V8S -- :PO()L' 101 rO -421,-000
ELECTRICAL FEE -- €'OUL 101-000420-W0 194510
�
'i',L:Ux' BINTOFEE�-PCSL 101000.419-000 3217,00
rn
C� D7
SUS,TOTAL CONS RUCTION AND PLAN CHECK
032..90
LESS `1 RE-.PA.ID FEES
$0.00
awr% 1.a.... a✓ M,>.:aaWt Y.. a _S in as
ur.i [.a..Nv
F,
!`C3"!'A•[: >)';<dC%i. aC"t :P 11CI1 �1'` ': 1hS
321."
RECEIPT
DATE
BY
DATE RNALED
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
_:�jI
Final
Final I I
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond BeamApproval
to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
5—
Final
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
Q
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:
ceit,, aha w
MEMORANDUM
1/— 2 7 - 9S�
CASES- 3(P Locations) : 5 ��a �Eji
q 4 V1
Request (9) : ed4,� s,A2P ,.,� o -►c1 AcLs� aN,
� -�� � o / a -.•-tee .foo l � q �,c., s-,../�'
Your setback adjustment application is hereby approved, subject to
the following conditions:
Conditions:
1. Obtain a building permit from the Building and .Safety,
Department.
2. The other Zoning Code provisions shall.be-met.
3. If ground excavation is required, please contact Underground
Service Alert (USA) at 1-800-422-4133. The. service is free of
charge provided USA is given at least .two working days'
notice.
4. Additional Conditions:
After review it was determined that:
1. This adjustment is consistent with the intent and purpose of
the Zoning Ordinance.
2. There are special circumstances applicable to the property,
including such factors as size, shape, topography, location or
surroundings that justify appr Val of the adjustment. These
circumstances are:
Thank u fo our cooperation.
Sin ly,
c6lidu ity. velopment Depar ent
Att hments
CITY OF LA QUINTA
PLANNING & DEVELOPMENT DEPARTMENT
,APPLICATION FOR SETBACK ADJUSTMENT
CASE NO:
FEE: $100.00
APPLICANT: Submit this form with two copies of a scared site plan,
drawn to adequately depict the nature of the request. A nonrefundable
fee of $100 is required when the Application is submitted. Check must be
make payable to the "City of La Quinta"..
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.
APPLICANT%CONTRACTOR:
PLEASE PRINT OR TYPE
IA 12 Sfie r h • PDO 15
CONTACT PERSON (IF DIFFERENT)
MAILING ADDRESS: q3 - 2 75 mei d I50h St. 10,4101
(Address) (City)
DATE; IVO V 20 9!5-
PHONE
SPHONE 3 y7 s9 S9
C/4. y Z ZO
State) (Zip)
OWNER' S NAME: R i G� a Mrd S rta Ke r- PHONE
MAILING ADDRESS:
(Address) (City) (State) (Zip)
STREET_ ADDRESS OF PROPERTY: ,SZ -2-60 'AVe Vl,
LEGAL DESCRIPTION OF PROPERTY: LOT #
TRACT
ASSESSOR'S PARCEL NUMBER: j
ADJUSTMENT REQUESTED: 3 S eT �A c k o r s t w pct-Ojz Q
REASON FOR
a.arXvuua . -, , N.—
y y yy.y yy y y y .yh yy y yy yy y y yy
JUSTIFICATION: No request for a Setback Adjustment shall be granted
unless it is determined that it is consistent with the intend and purpose
of this Ordinance; that there are special circumstances applicable t.o the
property, including "such factors 'as size, shape, topography, location or
surroundings that justify. the approval of. the adjustment of the setback
requirement, and that the. adjustment will not be detrimental to the
health,. safety, and general welfare of the community or be detrimental to
property in the area of the parcel for which the adjustmen_ is requested.'
FORM.013/CS
el�..
western �o.ols
CUSTOM POOL/SPA BUILDER
SEPWNQ.THE DESERT AREA FOR 18 YEARS
ROCKSCAPE SPECIALIST
347-5959
P.O. 80X 1047 INO O LIC. #348768
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