9906-068 (PAT)LICENSED CONTRACTOR DECLARATION
C/) I hereby affirm under penalty of perjury that I am licensed under provisions of
1— Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
N W Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
o O LO 344248 C-61 04130t20t
LLJi
Z to Signature of Contractor�>�%
CD
J L •• OWNER -BUILDER DECLARATION
W LULU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z ( ) 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).
cr) () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of ,Owner
rn
FL z WORKER'S COMPENSATION DECLARATION
C=) cc I hereby affirm under penalty of perjury one of the following declarations:
Lo O () 1 have and will maintain a certificate of consent to self -insure for workers'
X w �: compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
m Q U ( I have and will maintain workers' compensation insurance, as required by
O VQ See ion 3700 of the Labor Code, for the performance of the work for which this
11 rn t— permit is issued. My workers' compensation insurance carrier & policy no. are:
Ict Z Carrier Policy No.
w Z) i'taTFUND 065171^5 8
r0.
J (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
3 subject to the workers' compensation provisions of Section 3700 of the Labor
C de I shalrfo Kwith comply with those provisions. J
te: �APPlicant
t, Warning: Failure to secure Workers' Coompensation coverage is unlawful and
shall subject an employer to criminal*'
penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety,.
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, &-shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
• correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Qiiggnnature (Owner/Agent) ^ .-+r � ? � ' °.f�Date.
71V_ .ter •r v � -'�� v '
BUILDING PERMIT PERMIT#t�Q$f' r
DATE VALUATION &Z,:00*1 LOT TRACT
JOB SITE' 4i.133 Ylr#.f�itKNII3NA
ADDRESS
APN t,
OWNER
CONTRACTOR/DESIGNER/ENGINEER
PAtff-'%%r ALT..M.N
`"13NY M. YI3:1.R'RA CC3NSM CO.
48133 `/IA IIEI MOSA
Stip SIVRG.CON 1313, VE
LA <, UFNTA CA 92253
COT A MESA. CA, 92626
{7t4)97St-540.2 OBIN 4240
USE OF PERMIT
C'A'I 0
ALIii1'At7i+'e' OD GOWR 9.5'X 13'& 4" X IG IC80 5038
PORCUrTIA710 01"r,
,1F.SI•.Y IAUTI D 0031'r a �F COIN` TI.1.UCI ,.I ON
.�b,a1T17Y.Y1./
P1 qR&HIT PTE SUMINURY
pt.ivq Ci-iEt:K F0 101-000-4:39-3123 x+35, tit
,MRONI G N40TOX-1 M - )Cti.31D 2011 -000 -241 -OW
0
S1A3-1XY AI, C tNS'T12:UC110N `1NQ PLANCH?rK
9A0
LESS PRE-R.AWr;ES
$0.00
LIP'a�`1f�
o. `sa, jstt :a° 111PIUS OV -NOW
swfio
JUN 151999
1ITY &— A
r
RECEIPT DAT BY r 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
BLOCKWAI I A PROVALS
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 Wining
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
Final j
Utility Notice (Perm)
COMMENTS:
EXHIBIT 111n.
ARCHITECTURAL IMPROVEMENT APPLICATION,AND AGREEMENT
J.;
-DA
TE
NAMES) rt' a2i�'t CL! SCrJ " �'TLiUi�LrcU7E ..7
(Print)
STREET ADDRESS - V/"
t ,r,
LOCAL PHONE 576- V- 5-6 / 7 OTHER ' PHONE
REQUESTED` IMPROVEMENT
-P;i •g-� e i ell ( J
}Ap.proval " is ; requested :for -'the. .above improvement • E.ccording to.'
the."' plans'r,attached,.' ' We have . attached two' . (2 )' seas . of :`plans
outlining "the work"ato -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 Contract'or's License. `
'Att'achments r,.
(1Two` copies of -the Architectural Impr.o"vement Application..' .+)
(2)'" Two sets •ofplans'with'�materials and colors to to used.
On'e. set .pis:• for " the 'management office-; the other.
' set. to be returned to "you 'as "Approved". .
(3) Cont`ractor's name and copy of [contractor's li.,cense.. (Not-
r
required' if • -the improvement is. under $300.,.00.... or •,if
."Owner -Builder")
..1 (4)' f Brochures-, (2) and/o '• color' sample's of ma.r.ufactare'd 'products
to -be used'.
We have read 'the -Ar'chitec'tural Committee Rules and Guideline -s.
and have 'furnished copies to all' contractors to be "engaged byt
us and "we agree to comp.ly' with those, Rules and Guideline's.`
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 f:or."'
obtaining ,them, and the -subsequent _inspections°. wi,ll.:be. our,..
responsibility. In -all cases we recognize, the requirement to
.• be in compliance -with applixcable building codes including, but
not limited , to, • those" 'ad:opted' , subsequent to the,,, ori•g.inal '
completion -'and acceptance 'of our 'dwel-ling.
Rev. 4-96 }` ,'
Page Two
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 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 landscaping 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
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'implementat.ion
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,, a.nd
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 approre.d 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.
Signatures of all Owners:
(Signature) ( ignature.)
Rev. 4-96 ..
ARCHITECTURAL COMMITTEE CERTIFICATE
(Exhibit "A" to the Architectural
Improvement Application and Agreement)
The Architectural Improvement Application and Agreem,nt
reviewed by the Architectural Committee on L - 2 -7 -and
been:
Approved v Conditionally Approved Rejected
subject to the following
conditions set forth below
Returned for Further Information
Required.Modifications
Comments
was
has
Yes No
' Recording to be sent by owner to County Recorder's
/office for roof and/or exterior wall modifications.
Deposit Required Deposit. Amount Required $
Date l' Architectural Committee
A.r,hitectural Committee Architectural Committee
A itectural Commit ee Architectural Committee
NOTE: THIS APPROVAL.IS VALID FOR 90 DAYS FROM APPROVAL DATE
Rev. 4-96
COMPLETION INSPECTION
` Completed
work"insp;ected and
approved Date:
j;..
' Deposit
return. authorized
(if applicable, and
less any
reimbursement "to the Association
for costs incurred
to', bring
homeowner into
compliance•wi'th the
gover,ni'ng documents).
`.,Recording�
verified.
Comments
:Signed:
Date:
Date:
" .Architectural.Committee
it
Chairperson
;
�. ; . ..
1.
� ' -
..
✓'
Rev. 4-96