9601-180 (AR):? LICENSED CONTRACTOR DECLARATION "`
I hereby affirm 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. $1,6,770 13 / `3ii97
License # Lic. Class /" Exp. Dpte i
Date i SignatureofContractor /v.444 9112
OWNER -BUILDER DECLARATION
I hereby'affirm 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:
Carrier S'PA,Pr'y Tivt'f Policy No. Iiis141-y5
(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 proyylslons�cf'Sectio�n 3700 of the Labor
,Code,, l shall forthwith comply with those glovisigns. %//
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 3766
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 ore pursuant to
any permit issued as a result of this application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 160 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 insp tion pu.p0 S.
l Signature (Owner/AgenQ /0/1 Data
ALCM R"" nimn, PFRMI 1
JOB SITE ADDRESSAPN
Ii -52:j Vig,A. A�I4 N'fANA 769-330-09
OWNER CONTRACTOR
Tt ..'MOi'.E CONS'T13OCT±ON
R1C13ARD & LALrRA 810MNE' 74.1894 ( NPduN PLACE
501 WSTA MON:i ANWRD PALM DESERT CA 92260
INDIO C.A. 9U201 (619)341-7942 C13L# 2581.
.DESIGNER/ENGINEER •
I USE OF
R00M A001110N
CUSTOM f:i: NST1171ICTTON S o.00 SP .:'.
X.r1i'Ir',1E%T1E'D'C0.T1'
Of' Ci'o,tS'£RIU $'rO:Pe`
PERMIT .00i titT>oi�(1 AUV
Pr AN CHECK. M- "
1,014110-439-318
S239.85
;:ONSTRIUCTIONFEE
101-000413.000.
$369.00
JMEC.GkMC'ALFEE,
101-QG0.417V 030
,o>s,00
13I z t:'V.K1CA1: FEE
101-000.420-000
$34.21
P1.Ut1 ff b1>ti�0 FEE
1.01-100-419-000
STONC#:NIM 10N FFE - f2ESIO
S4 ?
i��iF�:l.liN�1!�'jSiY
11:01400-241.-nn�0��..:=--
1{11-U{f{)"HLA*v{)i)
.Ppc�.V.03'
CI ill -TOTAL CONS 71 , -J O`NT AND P:L,%N C'14EC.K
LESS 'PILE-P.AT13 't 8E 3
D � j.
FEB 01 TO3'1FRN'6'1' FET.S DUE NO'S
1996
By
I RECEIPT I DATE
INSPECTOR.
$6$2.39
$692,38
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 2 - -
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing -
Compressor
Insulation - Gj LGe-
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
POOLS -SPAS
C 1 BLOCKWALL APPROVALS
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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
,
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)
COACHELLA VALLEY UNIFIED SCHOOL DISTRICT
CERTIFICATE OF COMPLIANCE
(Government Code 53080)
Project. Name:
Project Address: 50-521: Vista Montana, .La Quinta, CA 92253
Project Owner's Name: Richard and Laura Browne., Phone No.:341-7942 .
Project Description: Room Addition (one)
Building Type (Check'one): Residential !�X nclude No. of Dwellings)
Commere Industrial
TractNo.: Lot No.:
(If tract, attach Schedule "A" of all lots by tract, square footage for each lot and total.) ;
Assessor's Parcel No.: 769-330-009
(If Schedule "A" is used show Assessor's Parcel No. for each lot if one exists or Assessor's Parcel No. for parcels before subdivided.)
Total square feet of Building Area: 550 Sq.Ft..
Certification of Applicant/Owners. The person signing certifies that thJ above informaiion'is correct and makes
this statement under penalty of perjury and further represents that he/she -is' authori to sign on behalf of the
owner/developer.
Dated: l Signature:
City/County Certification: -
(Signature) Optional
- j
(Title)
SCHOOL DISTRICT REQUIREMENTS FOR THE ABOVE PROJECT HAVE BEEN OR WILL BE
SATISFIED IN ACCORDANCE WITH ONE OF THE FOLLOWING (CIRCLE ONE):
Gov. Code Gov. Code Project. Agreement Existing) Not subject to fee
53080/65995 :. 65970. Approval prior to 1/1/87 requirement.
Note:
Total Number of Sq./Ft. 550
Amount per Sq/Ft. '-$' 1.72
Amount Collected $
School District Official U ! Lw!S/5/M-
VTitle: Asst. Superintendent, Administrative Serv.
och "Tut" Pen is
Date: January '30, 1996 Phone: (619) 399-5137, Ext. 235
Note: .AB 2926 and SB 201 fees are capped at $1.72 per square foot for all residential construction, and at $0:28
per square foot for,commercial/industrial projects.
d
._71-
T H Fa 1 -i S-.-• W E L�„ 1 i _ 1• T R_ ha 0' i' 'E - -C C, ha T R U C T I U F -a F "0 1
LAP! . ITYr"N A 1 T ArVE
ASSOCIATION
l c/o FOR ` &ST. MANAGEMENT
G. E. IM)LE COMPANY
78-900 T1 Pa"O" , U,40 9: UZunr)
Pnlm bort, CAUQMin 92260 (L�_}✓j
f %
(619); $46-8062 FARC (61.9) 779-1370
`Jan-ddry 25, x996
y Richaid Browne.
74-894- Lennon Place, Suite C -l; .'
Palm :Desert 92260
341-79x2
�u�t� ' STA -M
TAN`A TRdTf. ARS pl,Tra►'ei()N
Dear Mr. Browne
7r .1
_.The Architectural Review Coxnvaitiee of La Quinta Polo Estates Association
his reviewed your plans for, . re?ea atior� of the residential structure -and has
. gproved `your plans.
"-RCA lic�ztion Sana owe of t/he two sets
Attached'.is a signed copy of the A
pp
of plans submitted: ,The Association will retain onet of plans ' and will require
s, f inal insp'e'ction. of ter the structure is completedd.
If we can,, be- of any further assistance please call the management office at
(619). 346-8052;'
Thank .you."
FOR °THE ARCHITECTURAL, REVIEW, COMMITTEE
Gary W iedle, PCA.M CCAK 'Managing Agent
• FORTUNE WEST MANAGEMENT, AAMC ' ,
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