0102-216 (PAT)LICENSED
CONTRACTOR DECLARATION
,I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (c6mmencing with Section 7000) of Division j of the Business and
Professionals Code, and my License is in full force and effect.
Licerisdi Lic. Class Exp. Date, --/-
Z
5
Dates 'o-ontractor
Signature of
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I Am exempt from the Contractor's
License Law for the following reason:
1, 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 (Sep, 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with ilcen6ed
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:
Carrier I Policy No.
MWITIMI 0N M111
(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'corlipensation laws of California, an�agree PU
that JJ_l_Sh Id become
_1 -should
subject's the workers' compensation of Sectibn 3700 of the Labor
Code, I shall forthwith comply with tho ns.
ate.*. —,;! X�,O/Applicant _ P5�Q��,
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Warning: Failure to secure Workers! f Compen I sation coverage is undOul and
shall subject an employer to criminal I 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.
i.�; 1..Each person upon whose behalf this application is made & each personfat
-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 a4lvoid 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 informatiori is
correct.(,.agree to comply with all City, and State I-aws relating to the building
I -onstril
, e re
�tion, and hereby authorizpres�qWves of this City to enter upon
,0'lth`e�above-mentioned propert, for insecfion pur oses.
Signature (Owner/Agent) 7,14&4le ate
I I , BUILDING PER
DATE VALUATION
JOB SITE
ADDRESS
OWNER
ITPERMIT#
W" Awlylor
48-1,13 1 V1,& _HRMOMN
LA Q13MA CA 922i3
USE OF PERMIT
LOT 0102-21,6 TRACT
APN
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CONTRACTOR/DESIGNER/EN INEEi
XT. CONMWrlog
,7 8 -62o
LAQIHNTA CA 9.2253
(619)564-2176 CBLO, IMA
UP X 701' RATIO GOVER P9R. APMWED PLA14S
240.00 53F
Esummmo cosu 01-1, loo-Namucruml
FER"WIT rkml, SUMMARY
PLAN cl-JECK ME 101-000-439-318
CONSMOCTION MR; 101-000-419-000
STRONG MOTIOV FEE - USID 101-000.241-000
FEB 2 7 2001
I_ UUW
OUTS-TMAL COMMUTCrMH AND KA9 CIUM
Lhl"3,13 PRS -PAIDRUD moo
TOTAL 1:'` ERwr F41 -21s MTE X40W
IL
RECEIPT DATEBY DATE FINAL ED INSPECTOR
41
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 Wail Insulation
Condensate Lines
Party Wali 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 Pibg. 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:
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CITY OF LA. QUINTA
BUILDING & SAFETY DEPT.
APPROVE®
'FOR CONSTRUCTION
DATE BY
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FEB -20-2001 01:42 PM P.04
ARCHITECTURAL COMMITTEE CERTIFICATE
(Exhibit "A" to the Architectural-
Improvement
rchitectural Improvement Appli.cation,and Agreement)
The Architectural .Improvement Application end Agreement was
reviewed by the Architectural Committee on and has
been: '
Approved 'Conditionally Approved Rej'eeted
r subject to the follovin;
conditions set forth below `
�. Returnid for Further Information 10�: �•t/ f "
Required Modifications
Comments
Yes No
Recording. to' be sent b oaner to County Recorder's
office for roof end/or exterior'wall modifications.
Deposit Required Deposit,Amount.Required $
C7 f
Dae Arahitectural Committee
Ar, it' ct r omm ttee Architectural Committee
f '
r t ra mmi teeAr;, itectura ommittee
NOTE rS THIS APPROVAL IS VALID FOR 90 DAYS FROM APPROVAL DATE
Rev. 4-96
FEB -20-2001 01:41 PM
Page Two
P. 02
The Association has no responsibility whatever in achieving
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 Restri.ctione, We also understand
we are responsible for the bccure,te determination of property
lines and setbacks (as -applicable).
We also understand that we will be responsible for ail costs
of this improvement and for costa- 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 wells, lawns,
plants and drainage. Further we recognize that any modifications
to the common area irrigation and landacapi'ag 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 ourstelves, as; well as for our
successors: and assigna, 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 th-e 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
P. 03
Page Three s
- We"furthe'agree that this improvement` will be completed in ,4
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, Z) if we fail to complete' this
improvement within the allowed time L 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 authorizei! by us in the farm 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. ,
TSignatures of all Owners. J '
V k.,
Signature: (Signature)
Vit: - t ..3 � a . r •
"Rev. 4-96`
r