0206-176 (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
L •Professionals Code, and my License is in full force and effect.
License #�j �+ 6 iL�ic.pC�llaass Exp. Date��vtt1} �a
>) t3 /6 f7 sib V4Fl 7�6J hl
Date f 4'` 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).
( ) I am exempt under Section , B&RC. 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 RXI?.Mp7 Policy No. Z$ESUD-LIST
(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 Irshould become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date:}' `�' Applicant—
Warning:
pplicant 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 vyhose 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 purpos'e's.
Signature (Owner/Agent) Date
W
�fBUILDING PERMIT PERMIT#
DATE VALUATION t LOT �r '� TRACT
JOB SITE,4 +��50t
ADDRESS -�aFN7A.1.wC R6N
4,7
APN
M
OWNER
CONTRACTOR / DESIGNER / EN 1NEER
47.,350 Wy �G�,I201
.i.26 ow:ice :t'�.•[�
p ry �`
J r1" QXGW TA VA � MR 253
�y,C�37�.�IRALA'�T�?• 1 Cr
3�a*S1..M I.�1& .G.i'C�.l� C,ltl. 927, 0
(760)779-C179C CRTC• 6448
USE OF PERMIT
Ctl?:MODF.L PER APP5?kWVU -PLANS. Sl B -141ST V•iSRIFT101
VALUATION &000.00 12
E'S'iRi MTM. a COST OF COA�,",iRrXM0,F
PIAN CHECK 3t FEE 101-000-439-318
CONroTRUCTION rEf✓ t01 -4J00-429-000 $-t7.V,;
ILEaMICALRX 101a aa•2.0+OW sas:�f>a
.."T, .PD"ND MOTION PAL. RJeSI.0 1614-60-241--'000 11.51fl
r � 'tett./ 1
juN 1. f
p NOAWCEDEPT
- = .x: 10 T Rr!,-PMD �+'.t55
$0.00
` olAll FERAffir111 Ii5S c'{)OYI NO`S''
$13430
e ✓"' ZY
RECEIPT
DATE % '
/ 7t ' !`
BY "� '^'
DAT FINALED•O
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
7 / —cam ai
Combustion Air
Roof Deck
'
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
_ Z
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls `
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
- (p
Final
Oy 5
Final
POOLS - SPAS
BLOCKWALLitp
ROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
..Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
-
'
Final
Utility Notice (Gas)
14 ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
F xtures
Main Service
Sub Panels
Extrior Receptacles
G.F.I.
Smoke Detectors ,
Temp. Use of Power
Final
Utility Notice (Perm)
FRS: WC BOVIS
Bin d
Permit #AA
0) e �`
w %LDi
City, ST. Zip:
Telephone: `
State Lic. #:
Name of Contact Person: 6
Telephone # of Contact Person: -)t-
submittal, Read Ree'd
Plan Sets
Structural Calm
Truss Cale$.
:Title 24 Calm
Flood plain plan
Grading plan
Subcontactor List
Grant peed
H.O.A. Approval
IN HOUSE --
Planning Approval
Pub- Wks. Appr
School Fees
FAX NO. 7607729319 May. 02 2002 12:53PM P1
3
City of La Quinn
Building a Safra Division
P.O. BOY 1504, 78-49S l"a!!t; Tarsaaico
La Quinw, Cil 92253 -11760) 777 61z
Building Permit Applicat►o!l and Wracking Sheet
U a -O .t,) Ovmer's Name: r'
Address: �O'�� City. ST. Zip; �— - q ?S 3
Telephone:
�j Project Description: ('1
k;
- t. t
Project Address:
Occupancy:
A. P. Number.
Project t}'pe (circle
Legal Description: LOT 14"?
l�M
Con
# Stories: # Units:
Address:
Estimated Value of Proiecl:
Citv. ST, Zip: -
'LICA : DO NOT WRITE BELOW THIS LINE
Telephone:
7 RACK N'G
State Lic. k ; �J-Z ��
(�
J O 163
Arch.. Engr., Designer:
w %LDi
City, ST. Zip:
Telephone: `
State Lic. #:
Name of Contact Person: 6
Telephone # of Contact Person: -)t-
submittal, Read Ree'd
Plan Sets
Structural Calm
Truss Cale$.
:Title 24 Calm
Flood plain plan
Grading plan
Subcontactor List
Grant peed
H.O.A. Approval
IN HOUSE --
Planning Approval
Pub- Wks. Appr
School Fees
FAX NO. 7607729319 May. 02 2002 12:53PM P1
3
City of La Quinn
Building a Safra Division
P.O. BOY 1504, 78-49S l"a!!t; Tarsaaico
La Quinw, Cil 92253 -11760) 777 61z
Building Permit Applicat►o!l and Wracking Sheet
U a -O .t,) Ovmer's Name: r'
Address: �O'�� City. ST. Zip; �— - q ?S 3
Telephone:
�j Project Description: ('1
k;
- t. t
Total Permit Fecs
�� 7� s
Consttvction Type:
Occupancy:
Project t}'pe (circle
Add'n Alter Repair Demo
l�M
Sq. Ft.: ,
# Stories: # Units:
Estimated Value of Proiecl:
3'
'LICA : DO NOT WRITE BELOW THIS LINE
7 RACK N'G
PERMIT FEES
Plan Check submitted / /
Item
�Q
Re.iewed, ready for corrections s
Amount
Plan -heck Deposit
A/
Called Coniact Person
Plan Check Balance
•
Plans picked up /�
Construction
Plans resubmitted
11eeh:6ica►
Review, ready for correctionslissue
Electrical
Called Contact Person
Plumbing
Plans picked up
Plans resubmitted
Grading
Review. read- for corrections/issue
Developer Impact Fee
Called Contact Person
A.I.P.P.
Date of permit issue
Total Permit Fecs
�� 7� s
ot�
Lake LaQuinta Association.
ARq ,rECTURAL/ LANDSCAPE REQUEST FOI-RIJ
hot
date 3. bmitted: d Yr Date Received:
Owner Name;s):
' }✓'r�pe:'t�' Acadi•�ss: ���C..L�¢---�C�%�.tl----------- •----_..
Local Phc-ne: _`lql 3 7-9 ether Phone: ---- --- ---------- — ..
Mailing A•_ldr(:ss: — �w� . -- --- -- ---- ---- -- ---- -_— _—_...._
(If dii}crcne front property addtcsu)
If applicable:
Arc1-iit:.ct/Contl�ar.tor Name: .--^_!___.---•--- _.._-_- �
Tcicohonc; — -- —
The: following _irscribr-d modifications arr, proposed and approval is regi.3ested in accord:wricc, with the:
Procedures o_ din�G in t` -t ks:',cciatica'8 :i; clli'.:ectl:ral` ,cilldsca;�e GUi=lelineS (`_lt?reirl .Itel' °C,uSCI('liT:es")
Description. cf prcjcct ll�r:.iilaftt:r _1Yl l wea:i nt jC _ ? r:
(Pleclst pluvidc d cui,_Nlrtr, latirrdiivt liesc liNliul: of t?tr flr (IUSCt� IIIUCIIfiUAUUtI dl!d iueluJr druwiugtj at; Hl pjtji,t'i!ilz ).
This Arehitectural/ Landscape Request Form shall be. accompanied by:
1. All copies of Plans and specific« io.t_si as einlmeictted in t:i1e Application VroceclLlt'e,
1'�rl.inlr. fl?, wif.iiiTi t.1 u•: C-uillr.Gnrs
2. Complete ,rirCillLei tura) ini.rcwen,lt:.,t Agreernert,
3. Neighbor's C nll'i":i:Ilt3 S:CL:C•ll, Vv!-,:rc:.al]pheablic. a1S4 w) , o
THE APPLICANT UNDUE S'TAN;_"%S AND AGREES 'CO THE FC)1_j,.plrjilJ I
L Th.r modifications x;'_11 be inajt _'1 strut ct !�lplial:rc lTitll t';e tl;pr vrd pla,ls end si5� cifi .a.tivl a
:3L1b111ltfCd P:lt:7 this applicatic . VSllctlld. ar_y' change s'bc rcr4Ul)'i .,, at etr..�, til?; dlli',Ilkj th prO C:.t gl? ti�
ti -
Changes must appr�yec! ill.�.dv t:' the Arcf_itecturai
appHeation. !Ze:7.,ty ;on rrittet, wile riotedon t lis
2. Owner shall, hold L17e Associatiur_ harmless :roil aN liability related to an: d.arnaae to existing
!t-;;li1F;Ti('F;�� llfll)1'Q�'('"I'I(•:11i.S t}li'-f': �ili, ii11V ;.'(ill'171(i:3 %il't•ila 1)1'Uli('1•j.'�. -
3. A,-,licant shall ad-,-isp Asso:iatio_) office fr01-11ptly, open coraNi,:tloll of, the: >tior>i.
Applicant shall ccmpl, , %-,:tl-, the i rchiw(.1 ttrR1 J 1..anetscal�ing an-: Dcsigr r'wndards i'or
laikt: l.:d QtJi 11.a Ate\i%t1iil.ioT:'yf !1,'UtI;t)ili Ropirs :i1 111 , r lJrovisloI iii Ii) .i Jt: :7Clftl: 1,:11»'(s) t'-I Igmgt:iI
by Own-n. lo:' the 1n provC11 en . Appllnallt fur2.1:-:d: uriCi�sr5tarl ClR that. it 18 0-w CS'`S responsibility CU
onsurc that l-tia, her .^ont^scic-r(a) a:so With thcs�_ provisinns.
S. Applicant scall secure proper building, p;ertnits, if req;iiri:,d by tile: iocai govenirrient it entity.
Applicant understands that til%; City of L Quinta may not app1'ove any Plans w'CiCh have tim
;-et bet.0 appro'le:j by tyle Assec:a ic, is �tir:llite ii.( 1 L~^tt?(t'.IL'Cc
OWNER SIGNA TIURE (S)
Neighbor COMMOU$Si 011 _::rmenb *1 am owners of ar.4 rtonw acljaaa:)t is t1:e':operg itne, of tete �Jp�itcent's
impr'ovZntcn; s =nu be ral>.:u.cci fir awr_uigs, built-in. barbccucs awl cvatcr fcat+ur--s, cunc: cts 1Eusitna3l:c barlcrs (nurbirg)
walla, 1-'_i`Jt cooling s}-stecus- gena r crer.a.wv . ro JR / Spays, soon, additions / e.u'e' t:ces, spial tJ ut's'i1. ccrt ai,: Lees f palms and at,t:li
other improvetuen-s theAra.i:ecuu'sl Rec'i�w Ccinuuittee deen'.s a.ppropr:atej
i I We, the '.�ndC .-r ipied, have rri^clt'!:i1. ^�n,y 3ilgr-t d tl)e ptar�s and �ne_`.lficationd fo- ttle. C9Ji7VN 1'bCli-1(.:3(Et:l
a) prow. t 8.'1d i�`l.'r fll_nev: 11 ;.o not t�l��C't; to ihiis lIT;p ve i (2, o1Jj�'t F1'kh t` tr fr;jjOivjrjj
U 1': 1? Ol' I t r•
ocninnentB:
�FNeighbor!LAignaturej.PWMed Name f _j Lot#i _ Comments
............
�s
COMMITTEE REVIEW
.i
r APPRt.VEL�
as sr,i:r,�ittc i. Project to tie completed by: , ^'
r'? APPROVED subject to the follawing conditions: — �-
' DE!VIE3� for tl)c fc,lolF'ingr,.a3 ons: "—•---__-_--_ -- ---- -- _ _._.. -
1.El'D OVER peluhl:g fP.CCa:," ofiJ:':Oil;l±g 12-1101•".1Tappl1C;tiPt:
Comsalttee Member ftnatures:
APPLiCAIvTN --nFIED G- APTPG't/Fs 1,/DISAPPROVAL Date:
Permit #
Project Address:
A. P. Number:
Leal Descriatio
76 44(1/ov &ue 2�*Te
City of La Quinta
Bw7ding 8c Safety Division
P.O. Box 1504, 78-495 Calle Tampico
La Quinta, G4 92253 - (760) 777-7012
Building Permit Application and Tracking Sheet
Owttcr's Name:
Address:
�� !o O 3S� a
City. ST. Zip:
_ Telephone:
C �0- Project Description:
in•. ST. Zip: /
Telephone: xo ���
State Lic. # Cin Lic. #:
Arch.. Ener.. Designer:
Address:
Cite. ST, Zip:
Telephone: Construction Type: v. Occupancy: -
State Lic. #: Protect type (circle one): New Acd'n Alter Repair Demo
Name of Contact Person: Sq. Ft.: 00 # Stories: Units:
Telephone 4 of Contact Person: Estimated Value of Project: 0&7
APPLICANT: DO NOT WRITE BELOW THIS LINE
q
Submittal
Req'd
Recd
TRACKING
PERMIT FEES
Plan Sets •
Plan Check submitted
v
Item
Amount
Structural Cales.
Reviewed, ready for corrections
Plan Check Deposit
lcs.
TruE24
Called Contact Person
Plan Check Balance
Titlalcs.
Plans picked up
Construction
Flood plain plan
Plans resubmitted
Mechanical
Grading plan
2" Review, ready for corrections issue
Electrical
Subcontactor List
Called Contact Person
2Q
Plumbing
Grant Deed
Plans picked up
SAM.
H.O.A. Approval
Plans resubmitted
Grading
IN HOUSE:-
'"' Review, ready for corrections/issue
Developtr Impact Fee
Planning Approval
Called Contact Person
A.I.P.P.
Pub. Wks. Appr
Date of permit issue
1/2Z,
r—e✓ieal l
�3-
School Fees
Total Permit Fees
3� ,j
OWNER/BUILDER INFORMATION
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified.
For your protection you should be aware that as "Owner,/ Builder'' you are the responsible party of record on such a
permit. Building permits are not required to be signed by property owners unless they are perscnally performing their
own work. If your work is being performed by someone other than yourself, you may protect yourself from possible
liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a business license
from the City or County. They are also required by law' to put their license number on all permits for which they
apply.
If you plan to'do your own work, with the exception of various trades that you plan to subccntract, you should be
aware of the following information for your benefit and protection:
If you employ or, otherwise.engage any persons, other than your immediate family, and the wcik (including materials
and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or
subcontractors, then you may be an employer.
If you are an employer, you must register with the State and Federal Government as an emplo}er-and you are subject
to several obligations including State and Federal income tax withholding, federal social security taxes, worker's .
compensation insurance, disability insurance costs and unemployment compensation contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious -with
respect to worker's compensation insurance.
For more specific information about your obligations under.Federal Law, contact the Internal Revenue Service (and, if
you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under State
Law, contact the Department of Benefit Payments and the Division of Industrial Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their
work personally. or, through, their own employees, without a licensed contractor or subcontractor, only under,limited
conditions.
A,frequent practice of unlicensed persons professing to be contractors is to secure an "Owner /Builder" building
permit, erroneously implying that the property owner is providing his or her own labor and material personally.
Building permits are not required to be signed by property owners unless they are performing 'their own work
personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your
community or at 1020 N. Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of
these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
CITY OF LA QUINTA
DEPT. OF BUILDING AND SAFETY
78-495 Calle Tampico
la Quinta,CA 92253
(760) 777-7012
FAX: (760) 777-7011
OVINE NATURE/,DATE
P PERTY ADDRESS
PERMIT NUMBER(s)