0203-396 (PAT)U)
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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
261325 'fie'. O U31 /2f
Date -"'r 2J /U�Signature of Contr �c `�
c. -
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).,
( ) 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 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:
Cartier STATE YUND Policy No. 164050.2001
(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 -Sec tion 3700 of the Labor
Code,I shall forthwith comply with those provisions:
Date? �? ` 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 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/Age` `\t Date
1_ c ;
PERMIT #
F -BUILDING PERMIT 10203-,1.x,;
DATE - WaMlo , VALUATION &3,47130 LOT TRACT
JOB SITE ADDRESS 40.201 CLAY 1.+'.:.�01�7� AS APN
OWNER CONTRACTOR / DESIGNER / EN (NEER
413-201 MilsEMO1 MAZ78.155 CIVAJEZLWUNA
LA QUINTA CA 92213 IA QL7.N.T"A Q -V 922 a 3
(mop,71UO71 CLIO 6M
USE OF PERMIT
pA Ao
261 Sly AL;UFAAi'+l00D I.,A I-TI%E:.PAf'IO CCNF-R
110AI.CHI Ai i IO
20100 OF
11 STIM ,f1:3 COS'' or �;C�1`T�"k°1�i'I,TC3:�O N' - 1141
P MMIT KIM SUMMARY
PIAN CIM -K FEE 101.000-43.9-318
CONM'RUC-1107 FF?P 101-GVv-418-000 MAID
STRONG MOTIC44 "I'ER - RRISIU 101-000 -2/11-000 5.50
9
MA'IZ 1002
AND PLAN M160K
1Al 111 ;5'REPPAZID FMIS
RECEIPT DATE
C'I BY DATE FINALED INSPECTOR
-;i_'7r�tr`
3141 k zvo
$104.4:3
$01 DO
$1 f74
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
D II - Int. Lath
A
-02,. S .
Final -0 C_S. -
BLOCKWALL APPROVALS
Final
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
I 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
Fbctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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EXHIBIT "1"
ARCHITECTURAL IMPROVEMENT APPLICATION AND AGREE ENT
NAME(S)
STREET ADDRESS
DATE
(IPrinN�II�/��l S
LOCAL PHONE OTHER PHONE
REQUESTED
-5 01- 0-;^k
IMPROVEMENT Z� r w�'� C/
V -d' 'C' laA,6
Approval is requested for the above improvement according to
the plans attached. We have attached two (2) sets of plans
outlining the work to be done along with a complete description
of the materials and colors to be used. If we are using a
contractor(s), we enclose copies of the Contractor's License.
Attachments:
(1) Two copies of the Architectural Improvement Application.
(2) Two sets of plans with materials and colors to be used.
Note: One set is , £or the, ma,na.gement.. office;, the other
set to be returned to you as "Approved".
(3) Contractor's name and copy of contractor's license. (Not
required if the improvement is under $300.00 or if
"Owner -Builder").
(4) Brochures (2) and/or color samples of manufactured products
to be used.
We have read the Architectural Committee Rules and Guidelines
and have furnished copies to all contractors to be engaged by
us and we agree to comply with those Rules and Guidelines.
We also understand that it is our responsibility to insure that
our Contractor(s) comply with said Rules. We acknowledge that
Building Permits for home improvements may be required by the
City of La Quinta. The cost of permits, responsibility for
obtaining them, and the subsequent inspections will be our
responsibility. In all cases we recognize the requirement to
be in compliance with applicable building codes including, but
not limited to, those adopted subsequent to the original
completion and acceptance of our dwelling.
Rev . 4-9`6
OVER
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Page Two
The Association has no responsibility whatever in 7achieving
compliance with newer building codes which apply as a result
of Homeowner prompted modifications. Further, we understand
that approval will not be granted for any modification which
directly or indirectly conflicts with the Declarations of
Covenants, Conditions and Restrictions. We also understand
we are responsible for the accurate determination of property
lines and setbacks (as applicable).
We also understand that we will be responsible for all costs
of this improvement and for costs associated with any repair
to common area occurring as a result of implementing this
improvement. Examples include, but are not limited to, sprinkler
and irrigation systems, buildings, roofs, exterior walls, lawns,
plants and drainage. Further we recognize that any modifications
to'the common area irrigation and landscap'ing"-scheme, are subject
to formal acceptance by the Association. Any required remedy
to achieve the required maintenance standard or irrigation
standard are our responsibility. Additionally, we understand
that the job site must be left reasonably clean at the end of
each day, that no debris nor dirt may be dumped in common area
or left at job site. Any maintenance or replacement of permitted
improvements, except for certain landscaping, which are beyond
"initial" improvements, shall be the homeowner's responsibility.
We agree to indemnify for ourselves, as well as for our
successors and assigns, and covenant and agree to hold
Association harmless from all claims, demands or liability
arising out of or encountered in connection with this Agreement,
whether such claims, demands or liability are caused by Owners,
Owners' agents or employees, or contractors or subcontractors
employed on the project, their agents or employees, or caused
by any products installed on the project by said contractor(s)
or subcontractor(s). Such indemnification shall extend to claims,
demands or liability for personal injuries and/or property damage
occurring during installation, as well as after completion,
including, but not limited to, all Owners' maintenance
responsibilities provided herein.
We further indemnify and hold the Association harmless from
all liability related to any damage to existing improvements
(wherever located within the Subdivision) resulting from the
installation/construction of the Architectural Improvement
If required by the Architectural Review Committee, we agree
to record, .and pay for the recording, of this improvement at
the County Recorder's office.
We further acknowledge that the Architectural Committee may
require a deposit be submitted before work is begun.
Rev. 4-96
r;
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Page Three
We further agree that this improvement will be completed in
a reasonable and diligent manner. We further agree that 1) if
we do not correct any damage caused as a result of implementation
of this improvement or, 2) if we fail to complete this
improvement within the allowed time frame the Homeowners
Association may elect to complete -the work and/or repairs, and
we will be responsible for the actual costs of such work. Payment
to the Association is authorized by us in the form of an
assessment or monthly penalty payments as approved in the
Guidelines.
By signing this Agreement below, we agree to be bound by its
terms and conditions and any conditions set forth by the
Architectural Committee in the Architectural Committee
Certificate, which is attached hereto as Exhibit "A" and made
a part hereof by this reference.
SiAna$ures Af Aall Qwihers
gnatWe
gnature
Rev. 4-960k
(3*4
ARCHITECTURAL COMMITTEE CERTIFICATE
(Exhibit "A" to the Architectural
Improvement Application and Agreement)
The Architectural Improvement Application and Agryement was
reviewed by the Architectural Committee on 1,6Za-nd has
been: /
Approved `- Conditionally Approved Rejected
subject to the following
conditions set forth below
Returned for Further Information
Required Modifications
Comments
Yes No
Recording to be sent by owner to County Recorder's
3 office for roof and/or exterior wall modifications.
S _ Dep sit -Requ,kred De 1 A fired $
Date Ar ite ura C m' tee
Architectural Committee Architectural Committee
Architectural Committee Architectural Committee
NOTE: THIS APPROVAL IS VALID FOR 90 DAYS FROM APPROVAL DATE
Rev. 4-96
COMPLETION INSPECTION
Completed work inspected and approved Date:
Deposit return authorized (if applicable, and less any
reimbursement to the Association for costs incurred to bring
homeowner into compliance with the governing documents).
Recording verified.
Comments:.
Signed: Date:
•Architectural Committee Chairperson
Rev. 4-96