0107-276 (RER)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
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), 4
() I am exempt Nnder Section , B&P.�.C,,,//��for this r a
Date _ f: a ;� �� Signature of Owner `` + fa 1 If `- L
1NORKER'9'C6MPENSATION 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 ,Policy No.
MAW If
(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 provisioris of Section 3700 of the Labor
Code ,'I shall fo hwith comply with,hose pro6sions.
Date: '� to lie Applicant i' .4.•e.�R''"'1# -
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 Ouinta, 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) +r• % i Wt�:.%il _-.t.��� -- Date +)
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0107-2.76 TRACT
f3'l0 €ti1�t63C .S R)
JOB SITE t
APN e
ADDRESS
OWNER
CONTRACTOR/DESIGNER/ENGINEER
3? A14C:y DIME, 17
Row 15Giki' m Commucriox
50-4580 ,RAND A'y'r':T.e,' -,
41.010 YE1C?CAI AI'm '
LA Q?1FNTA. CA 9221:93
IAI7 10 C -A 92201
(()360-7307 (T. -IN 53 1
USE OF PERMIT
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dcu�:.�IaA FRE UMMMY
PLAN MECK AR 101.000.439.3.16 546,80
M? SIMI IGIr#?. w Vol?, 103-.00C-418-000 M 00
PONE k,9C9't' 0N, VIEW'- %3',SIT) 101-000-241,000
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L 2 6 2001 I&B''s��RI-11-PU)R'0$0'G0
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4.
T'! OF LA OUINTA
FliilANCE DEPT
140
RECEIPT
DATE
�,
BY
DATE FINALED
INSPECTOR
{r�
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
BLOCKWALL APPROVALS
Final
Steel POOLS -SPAS
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) r''
u 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:
LA QLJINTA FAIRWAYS HOMEOWNERS ASSOCIATION
AVAIL PROPERTY MANGEMENT
P. O. BOX 1032
PALM DESERT, CA 92261
June 4, 2001
I;
i Donna -Lee Ekstrom
P.O. Box 284
Palm Desert, CA 92261
RE: Architectural Variance Request
f
Dear Ms. Ekstrom: .
Your request for the changes to your house were reviewed by the
Architectural Committee and approved as submitted.
All permits from the City of La Quinta must be obtained prior to the start of
this construction. No debris or materials may be left on the street overnight
and the area must be cleaned on a daily basis.
Thank you for your cooperation in this matter.
Sincerely,
Cam Anderson
Project Manager
.-.:CITY OF LA QUINTA
BI�ILDINC & SAFETY DEPT.
APPROVED
FOR CONSTRUCTION
I DATE 7/lam/I BY KK110-'
TOM HARTUNG DAA=JERRY?1 RMAN KURT
BUILDING & SAFETY DIRECTOR CWMU,NITY:':DEVELOPMENT DIRECTOR R.C.E: 4
CITY OF LA QUINTA CITY OF' .LA :QUlNTA SAXON;
or
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