0202-098 (PAT)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
C61 3.1)24 13S7iV
Signature of Contractor * f'-� -a'r � '�A +,_,=d
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
WORKERS 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
Soction 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 STATE p_L13"t) Policy No. 06..S3i;5-Aa
(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 Section 3700 of the Labor
Code, I s all forthwith comply with those provisions.
Date: Applicant ;r,,..• `v a•+.+�� -+ c .
Warning: Failure to secure Workers' Compensationlcoverage 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, indemnity
& 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.
DateA.) 1Vt —
v
�-- BUILDING PERMIT PERMIT#
DATE _ VALUIrTION-- " LOT :1 " 33E3 TRACT
JOB SITE <
ADDRESS
APN
48-113 VIM (,T ',O
OWNER
CONTRACTOR / DESIGNER / ENGINEER
i?rIB3 L.lt`ZIBM
T014Y M YEARRA CONST. . CO.
7e-664 CIUM-0 COt.RT
IA Q'UfATA i".A .92253
ME RA CAf. 92.626
0114)9?9R >493 CV1,41 +3 M0
USE OF PERMIT
PRno
290 S37 Al,;U'Ix1AW000 t...l TTICF, IP t IO CCi , 1011. kika.l3 AkPR0\r,A.L
CON It"i;:F. N59r)
Porte",ATIO 290,01) OF
YY.fl
ESTU' UD 00frX OP CeaNS IC IOiii
3,F;a:r7Yv. 0
fix" CHECK M, 103 �000-439.3 i F MOM
CO.N e` (iCT it, U
S 1 t�lJi)1� '1itil�1, L 1t S1 S 101 -000 -?AI -000 - $1,50
IVFEB 11 2002.1
LAQUIRA
C00F
�iY i'f'CCXkJ-COA,tMUC17..09 AND
$104AS
TOTAL MMUT "TS OWNOW
VISM,45
RECEIPT
DATE f
BY_-., -
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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings 1
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
rws)6wer 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
Foctures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
NO"
q. 30. 07
m
�i
FEB -02-2002 09:31 AM
P.01
RECEIVED JAN 2
8 2002
iRd91TB&UkAL jHpjt0VZkkHT'. APPLICATION AND AGR ISHENT
DATE
dtkn PHONE
REQVESTEb.. tkROYENW
eutye LO X.E7
IN
�LOSSr_ sa _n4 4S 0 AA OR
"Bala
Tl Appro0i1% id request od for the: -iib6ve improvement a
fting to
cc
th
'-
. % .. . ii- -4ched. . tvo -- (2). sets of plans
-h . P - -
:"-
e Oians:gitach6d" We ave
outlitiifig the work to be ddihb 61 fig'. with a complete description
-
of the mdj.eXiajs and c6 e used If we Fare using a
'License.
Contractor's
ka., copies Of. tNe
ont cidrit a.) iwe enclose
vemezit Application.-
e
x T
b Archit
2)-;TU.b!Aq6td - :and colors to be used.
of -0lahr. with mat-46r,idik
n office; the other:
pit '"Approved" -
` b, * ifi, �.4% -• , ij.-'
t o. e r u y
(Not
ontractor's license4
name and 'c o -P Y.. 0 c
.' "
$300.00 or if
impv ' is. . 'under
if the ro aji
"owner—Butlde r
manufactured products
(2) end/or color of
do 16 used.
We hovi. jead. the'. Architectural Committee 'Rules and Guidelines
T copies
to all contractors to be engaged by
h.-.
th- th6si—Rules and Guidelines�
to ins that
thilft.'it
is,
06 6MId-,;RvL
jbe' EI act-,Powledge that
P
c with'. t If.:
k_6-: ir'n-7 h.? required by the
oi
-Auil orm L:a* jrghi t s i responsibility
of ',a--�Quin ai Thi- c s�t o for
Ci L - t, - 64tionte ihspections will be our
h
obtaining.; diem.. and the
uirement to.
-recognize the req
respo'fisibilityTh. all cases.:we .-recognize .
..,. .,h ' 'bi-iiI.01rig 'codes including, but'
be -diftPlian wil. CiPP#d
ubsd4utnt to the original
nOt h0aa,.: 0 a a,......
96
F -EB -08-2002-09:32 AM
P.02
.%Y
page Three
we futthtfr i3trse that ONAO iri-WOO-alt t-" ha compleved in
-W#j furcher agras that 1) if
e:.. 0 J3
""V d ndt,. correct sity domsigo caused 65 result of iry 10
,lementat n
f
vs this
j. to complete
.,.within feta `ruwo t a HOT—novnOrs
pro� 'Mitit the ..ailoweid'
M L
.'Absoci6tith' OY - elect %:0 cOr1IP1iUti:.'-- ivork --and/or repairs, and
we` he 're'sp isibie fok the attuil'boats of such work. ?azyment.
e on
the i6ciatioft. -ItLad. b� 's Ju the form eif an
is s ii o k U AL
to'' .'Ass
-
is' is e s a ie: n f 6 r moivEhly OEM8", tY As tIP r 1! the
?Guidelines.
By signiig this Agreement beloi#, Oee. agree to be bound Sr ,is
t d -�v rLs set forth by the
ah _ditiove and al cl 11
"he
..Architectural cblimittea Architeatux-al
' he made
heal U.5 E x �,i bi t n n d m
Certificates which is attached
a part h u r a o f by this refe.*Ience•-
• -Signatures ui
(Sigwitp
FEB-08-2002 09:33 AM P.03
+ A CHITSCT'U�AL �o�f iTTT�$ C$RTIFICATE
• Ey +„s. ,rkxHipit �idii to t#� Ar hitecturel
_� b• ;`;;y Itnprrbveaien't �lppl�icdti'dli find Agreement)
The Archit®ctural Improvement AO ' icdtlan and Agreement was
.:revi6irtd' by the Architec.tt(ri, Colnt6ittee on end hes
:.. been s
^Appro4ed ✓ Qohditionelly.A pkove4. Rejected
dubject io the. df ibving
cetidiiiona..set fork% below
J.
....,.Returned for FurtPier' Information
Required modificetioAs
.Comments - �,....
Yes No
Recording to be'. sent. >by. oianer to County Recorder's
office for roof: and/aT '.�eiiterior .well modifications.
.��
Deposit Required De0osit Amount Required $
'Date; tr tectural Committee
Arc itoctt�r.a1 'Co tmitt is itecttiral Committee
e
ichit0dX= iei6 tree Architectural Committee
i6�: B s . 4kIs AP�$�v L IS .VALID F • '3 ! :iAYa PiV ' APPROVAL AAl'6
�I
Rev. 4-96